Jim;
Read your column regularly and thought you might be able to tell what the VA is up to?
I just received a determination that the following condition was related to my military service, so service connection has been granted.
Hypertension associated with coronary artery disease status post myocardial infarction and coronary bypass grafting(also claimed as ischemic heart disease, heart attack, and blocked arteries)(Nehmer granted)
Percentage assigned 0% . I am ok with this as my prescription for Metoprolol Tartrate 50MG Daily and Lisinopril-TCTZ 12.5 MG Daily have my Blood Pressure to normal.
We determined that the following service connected condition has worsened, so we granted an increase in your assigned percentage:
Coronary Artery Disease status post myocardial infarction and coronary artery bypass grafting (also claimed as ischemic heart disease, heart attack, and blocked arteries) (Nehmer granted)
Old Percent Assigned 10%, New Percent Assigned 30% I am ok with this rating.
The effective date of this grant is based on facts found documenting an echocardiogram which confirms evidence of cardiac dilatation.
We have reviewed your records and they suggest you may be entitled to an additional benefit.
We need to clarify whether you intended to claim an increase in your service connected Coronary Artery Disease (CAD). Please tell us on the enclosed Support in Statement of Claim (VA Form 21-4138)
That you want to file a claim for CAD and return the form to the address at the top of the letter.
My big question does the VA now consider Coronary Artery Disease CAD separate from Ischemic Heart Disease IHD.
When I filed my initial claims for IHD I also included a Myocardial Infarction and Coronary Bypass Surgery when I made the claim and they were rated 10% for IHD no mention of CAD.
The VA has always been good with updates and information during the claims process. I like the VA Healthcare I get. They do a very good job. Overall the VA does a pretty good job.
The last rate change baffled me when they suggested an additional benefit which I believed I requested with my original IHD claim.
Thanks for what you do.
Reply;
The terms CAD & IHD are confusing. In my civilian career, I worked in cardiology and heart surgery for 35 years and we never referred to CAD as IHD. The term IHD isn't incorrect, it's just not used very often. To my mind, the term CAD is clear and specific and IHD isn't as clear. So, leave it to VA to use the more obscure language.
The people who write and send those letters aren't health care professionals. They aren't lawyers either but somehow they're supposed to be qualified to interpret medical and legal terms just as if they were professionals in those fields. They make decisions about your life based on rudimentary knowledge of complex medical diagnoses and legal theories and often get it wrong.
It appears to me that in the letter you received that the author of the letter is asking you if you intend to file for a higher % rating of your IHD. The problem arises when he/she uses CAD and IHD interchangeably. This is a known problem in all of medical terminology. When medical professionals skip around in using similar terms everyone can get confused and mistakes often happen. This is particularly true with abbreviations that are common to charting medications or orders for procedures.
I think that you should respond that yes, you do wish to file for an increase in the 30% rating. The rating for IHD (CAD) is driven by the function of your heart as measured by one or two standard tests. The tests determine the efficiency of your heart's ability to pump blood as it should. The end result is called the Left Ventricular Ejection Fraction, usually abbreviated to LVEF or just EF. The normal EF is in the range of about 60%. As that number goes lower, that indicates that the heart isn't as efficient as it should be in its task of pumping blood.
VA looks at 2 tests, the echo-cardiogram and the stress test. The echo shows an estimated LVEF and the stress test shows cardiac METS. I believe the echo is the more accurate of the two tests, METS are more prone to being a "guesstimate".
All too often, VA underestimates the LVEF number and you end up with a rating that is lower than you deserve. The VA also often ignores the significant scarring associated with coronary bypass surgery and you should be rated for both the incisional scar on your chest as well as the long scar on your leg or legs where the vein graft was harvested. Vein grafts are sometimes taken from the arms and the scarring there should be rated. Scars are secondary conditions to the service connected IHD and the law requires that they may be service connected. VA sort of forgets those in the process.
This is a complex problem. You may want to visit Stateside's page on heart disease at http://statesidelegal.org/ischemic-heart-diseasecoronary-artery-disease-and-agent-orange-0 and my page on secondary conditions: https://www.vawatchdog.org/secondary-conditions.html