RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01592
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070629

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty, E4 Calvary Scout, medically separated for “neurocardiogenic syncope” with a disability rating of 10%.  

CI CONTENTION:  “Bad heart, had to get pacemaker.”  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 - 20070608	VARD - 20071206	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Neurocardiogenic Syncope 	8299-8210	10%	Neurocardiogenic Syncope	7099-7010	30%	20071115	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40% 	

ANALYSIS SUMMARY:  

Neurocardiogenic Syncope.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s syncope (fainting or blackout) condition began at age 15 after passing out while playing the trombone.  The CI reported he stopped having symptoms around age 18, did not have symptoms for approximately 2 years and did not disclose his previous condition at his enlistment physical.  In the fall of 2005, he began having chest pain and received an extensive work-up including an exercise stress test where he exercised to an estimated 14.9 metabolic equivalents (METS) with no occurrence of chest pain or EKG changes.  During that work-up, in early 2006, he reported having pre-syncope during chest pain episodes and one episode of syncope after using nitroglycerine spray (a vasodilator that may cause low blood pressure).  The chest pain and pre-syncope sometimes occurred with activity such as physical training and sometimes at rest.  During a 30 June 2006 cardiology electrophysiology evaluation, the cardiologist noted the CI had a history of neurocardiogenic syncope as a youth and iatrogenic (medically induced) syncope following nitroglycerine administration.  After extensive testing and no diagnosis, the CI deployed to Iraq where he complained of chest pain with pre-syncope and returned to home station for additional testing.  During a 15-29 March 2007 2-week event monitor (with continuous EKG monitoring), the CI had two episodes of chest pain and two incidents of dizziness with no abnormal heart rhythm recorded during any of the occurrences.  

The 30 May 2007 MEB NARSUM examination, 1 month prior to separation, noted complaints of continued episodes of chest pain, dyspnea on exertion and lightheadedness several times per month.  Physical examination showed regular heart rate and rhythm with normal heart sounds and pulses.  The examiner cited a lengthy list of cardiac and pulmonary tests that had been accomplished over the preceding 2 years, all normal.  

At the 15 November 2007 VA Compensation and Pension (C&P) examination, 5 months after separation, the CI reported he had three syncopal episodes over the previous year, the last being 3 or 4 months earlier.  Each of the episodes was associated with exertion and consisted of the CI becoming dizzy, lightheaded and then everything went black with approximately one minute of loss of consciousness; afterward he felt weak for several hours.  Between these episodes, he had episodes of feeling dizzy without loss of consciousness.  He denied episodes at rest.  Physical examination demonstrated a pulse rate from 55 to 71 (normal 60-100).  Cardiac examination showed a normal rhythm.  The examiner referenced a September 2007 24-hour continuous EKG monitoring, which was normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the neurocardiogenic syncope 10%, coded 8299-8210 (analogous to paralysis of the vagus nerve: incomplete, moderate), citing moderate incomplete paralysis.  The VA rated the neurocardiogenic syncope 30%, coded 7099-7010 (analogous to supraventricular arrhythmias), based on the C&P examination, citing paroxysmal atrial fibrillation or other supraventricular tachycardia, with more than four episodes per year.  

The panel noted the vagus nerve supplies motor function to the roof of the mouth and throat including the vocal cords as well as autonomic innervation to the heart, lungs and gastrointestinal track; additionally, it provides sensation to the external ear and some sense of taste.  Given these varied functions and the pre-syncope or syncope symptoms involved at most, only one of those functions, and testing found no evidence of heart rhythm abnormalities with symptoms.  Members agreed this equated to no more than moderate, incomplete paralysis for a 10% rating, coded 8210 as adjudicated by the PEB.  The panel considered heart rhythm abnormality codes; however, with the CI able to exercise at a level greater than 10 METS, not on continuous medications and he had not had an implanted pacemaker, none of those codes provided a rating advantage to the CI.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the neurocardiogenic syncope.  

BOARD FINDINGS:  In the matter of the neurocardiogenic syncope and IAW VASRD §4.124a, the panel recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  Therefore, the panel recommends no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170227, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

AR20180007954, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	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.

Sincerely,					      
Enclosure