Question:
Does the BVA decision (dated 09/30/16, Archive Date 10/13/16, Citation Nr :1639405, Docket No. 10-43 947) have any affect on your thoughts as to whether Aortic Valve Stenosis qualifies within the generally accepted medical definition of Ischemic Heart Disease?
Jim's Reply:
The decision you mention can be found at Citation # 1639405.
I disagree with the conclusion that valvular disease falls within the generally accepted definition of ischemic heart disease (IHD). For the purposes of VA ratings the pure definition of IHD was published in The Federal Register in 2010 and says, "...VA interprets IHD, as referred to in the regulation, as encompassing any atherosclerotic heart disease resulting in clinically significant ischemia or requiring coronary revascularization."
In other words, IHD is an occlusive coronary artery disease and nothing else. The pages that VA provides for definitions also confirm coronary artery disease is IHD.
I have to back up just a moment and let you know that I am (among my other health care provider credentials) a cardiovascular technologist and I spent years working and leading cardiac cath labs, cardiac surgery centers and so on. The language used here is second nature to me and I can't think of any instance where anyone would refer to a calcific aortic valve as 'ischemic'. This may sound odd but the aortic valve is ischemic by its very nature. While it is bathed in fresh blood as the heart pumps, it doesn't have any large arterial blood supply like a coronary artery. Aortic valves are replaced for 3 reasons, the valve may become calcific and hard and not function well or it may be discovered that the valve has only 2 leaflets rather than 3 and with age that causes problems. There are also occasions where the valve may become infected with bacteria and require removal and replacement.
The case you refer to, Citation # 1639405, sort of says that but is about as muddled a decision as I've read lately. The author clearly isn't comfortable with medical terminology and the result is a mish-mash of terms that are used in the wrong way but reach the correct conclusion.
The veteran patient is said to have had IHD that was presumptive to agent orange. However it's noted that he had "non-obstructive coronary artery disease" and that isn't operated on. That's an odd comment to find but most of this report is off by a bit.
A bypass would only be done on obstructive coronary disease. The record says, "...a VA orthopedist stated that the Veteran's non-obstructive coronary artery disease..." and having an orthopedic (bone) doctor opining on a heart condition is typical VA and wouldn't be acceptable anywhere else.
I could go on but in the end I think that they arrived at the conclusion that the aortic valve disease was aggravated by the service connected IHD and thus is a secondary service connected condition to the IHD. While I believe that's a bit of a stretch, it's legit in the end.
I believe that if the veteran patient had presented with only the aortic stenosis (many AS cases do not involve the coronary arteries) he would have been denied presumptive service connection.
In any case BVA appeals do not establish precedent so thankfully, none of this terribly confused appeal decision will be used in another case.
Thanks for the interesting question!