RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01749
BRANCH OF SERVICE:  Navy	SEPARATION DATE:  20040901

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Hospital Corpsman, medically separated for “inappropriate sinus node tachycardia” with a disability rating of 10%.  

CI CONTENTION:  “Review all conditions.”  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 Medical Evaluation Board (MEB), but determined by the PEB 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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for the unfitting medical condition(s) at the time of separation.  The panel 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, which operates 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 disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20040812	VARD - 20050617	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Inappropriate Sinus Node Tachycardia	7010	10%	Tachycardia, Sinus and Ventricular, Status Post Ablation Therapies	7010	30%	20041117	
AV Nodal Re Entrant Tachycardia	Cat II					
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Inappropriate Sinus Node Tachycardia.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s heart condition began in 1997 with the onset of palpitations diagnosed as atrioventricular reentrant tachycardia (AVNRT).  She underwent ablations (blocking out portion of the heart nerve causing the tachycardia) in 1998 and 2000 for repeat AVNRT episodes.  An echocardiogram showed a normal ejection fraction and stress testing documented normal exercise tolerance (over 10 METS).  

Cardiac symptoms continued and worsened in 2003, leading to multiple cardiac evaluations.  Holter monitoring, initiated on 20 October 2003, showed five tachycardia events which cardiology interpreted as “several episodes of narrow complex tachycardia.”  Holter monitoring from 4 December 2003 documented two supraventricular runs with 24 supraventricular and 6 ventricular ectopics (irregular rhythms due to premature heartbeats).  Cardiology recordings from 7 January 2004 documented supraventricular couplets and tachycardia.  On 22 January 2004, the cardiologist documented “ECG: Sinus/atrial tachycardia, rates 90-130" and changed the CI’s cardiac medications, noting that symptoms were not controlled by current therapy.  In May 2004, she underwent an electrophysiology study and a third radiofrequency ablation of inappropriate sinus node tachycardia.  The underlying focus was unable to be ablated completely, and she had continued symptoms.  

The 28 June 2004 MEB NARSUM examination, 3 months prior to separation, noted CI complaints of continued palpitations following the May 2004 partial ablation.  Follow-up Holter monitoring showed no episodes of tachycardia, while a treadmill test revealed some increased chronotropic response (faster increase in heart rate than expected).  Cardiac examination was normal and the physician quoted the civilian cardiologist’s assessment of “status post ablation for severe inappropriate sinus tachycardia that has been unresponsive to medical therapy.  She continues to have some manifestation of increased chronotropic response, but overall is better.  Further ablation would have a very high likelihood of requiring permanent pacemaker.”  

At the 17 November 2004 VA Compensation and Pension (C&P) evaluation, 2 months after separation, the CI reported having a very rapid heartbeat, two different types of arrhythmias (ventricular tachycardia and inappropriate node sinus tachycardia), and a history of three ablation therapies which helped decreased tachycardia episodes lasting several hours to days down to less than one minute, once or twice per day.  Physical examination showed a normal cardiac evaluation.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the heart condition 10%, coded 7010 (supraventricular arrhythmias).  The PEB also listed AVNRT as a related Category II condition (contributes to the primary unfitting condition).  Members agreed the impairment from the AVNRT was properly subsumed under the overall rating for the inappropriate sinus node tachycardia to avoid pyramiding IAW §4.14 (more than one rating based on the same impairment is prohibited).  The VA rated the heart condition 30%, coded 7010 (supraventricular arrhythmias), based on the C&P evaluation, citing STR evidence of paroxysmal atrial fibrillation or other supraventricular tachycardia, with more than four episodes per year documented by ECG or Holter monitor.  The panel considered whether the CI’s tachycardia condition at the time of separation merited a 30% or a 10% disability rating.  A review of the STR showed more than four episodes of tachycardia documented by ECG or Holter monitor during the year prior to separation.  Ablation did not resolve the CI’s symptoms and stress testing documented increased rapid heart rate (chronotropic response).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 30% for the inappropriate sinus node tachycardia with AVNRT condition, coded 7010.  

BOARD FINDINGS:  In the matter of the inappropriate sinus node tachycardia with atrioventricular  nodal reentrant tachycardia, the panel recommends a disability rating of 30%, coded 7010 IAW VASRD §4.104.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Inappropriate Sinus Node Tachycardia with Atrioventricular Nodal Reentrant Tachycardia	7010	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20161115, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs

MEMORANDUM FOR DEPUTY COMMANDANT (Manpower and Reserve Affairs)
		   COMMANDER, NAVY PERSONNEL COMMAND	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 11 May 18 ICO XXXXXXXXXXXXXXXXXX   
	(c) PDBR ltr dtd 11 May 18 ICO XXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 08 May 18 ICO XXXXXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 11 May 18 ICO XXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 11 May 18 ICO XXXXXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (f) are approved.  The official records of the following individuals are to be corrected as follows:

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

     b. XXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 100 percent rating (increased from 10 percent) effective date of discharge. 

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

     d. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 40 percent disability rating (increased from 20 percent) effective date of discharge.

     e. XXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 0 percent) effective date of discharge.
 
2.  Please take action to implement these decisions and provide notification to the above individuals once those actions are complete.

                                  XXXXXXXXXXXXXXXXXX
                                  Acting