navy_619

Thank you all for replying, and for the help. I have a nexus letter from one of my pcp that I am including in my claim connecting my severe CAD to high cholesterol that was not treated back in the service. Now since they never gave me treatment to lower my cholesterol I have all my arteries clogged 100% RAC and 85% the left :( Now I can't even do much without getting a really bad angina and running out of breath...

Yes ma'am I have a nexus letter connecting my over 300 high cholesterol level to my severe CAD. When I was in active in 2001 they found I had hyperlipedimia with levelS over 350 and my condition went untreated and now I am a 33 yo with a heart that of a 80 yo.

Yes ma'am

Hi everybody thanks for the help you all give veterans on this forum. I have a question about IHD, Hypertension, etc. I am a 33 yo vet and I went to the VA a few months back with chest pains which I suffer from them daily and take isosorbide and nytro daily. They gave me a stress test and told me to keep going until I felt that I was going to pass out, so I was only able to keep going for about some minutes resulting on 7.3 MET's. Now could I be able to take the test again because I don't feel like it was fair and I got pushed to do more than I could. I am copying and pasting the results of my C&P for IHD can anyone give me some advice please? Sorry if the message it’s too long. Thanks again for taking the time reading this everybody. I apologize if the post is in the wrong place. Heart Conditions: (Including Ischemic & Non-ischemic Heart Disease, Arrhythmias, Valvular Disease and Cardiac Surgery) Disability Benefits Questionnaire Name of patient/Veteran: Indicate method used to obtain medical information to complete this document: [ ] Review of available records (without in-person or video telehealth examination) using the Acceptable Clinical Evidence (ACE) process because the existing medical evidence provided sufficient information on which to prepare the DBQ and such an examination will likely provide no additional relevant evidence. [ ] Review of available records in conjunction with a telephone interview with the Veteran (without in-person or telehealth examination) using the ACE process because the existing medical evidence supplemented with a telephone interview provided sufficient information on which to prepare the DBQ and such an examination would likely provide no additional relevant evidence. [ ] Examination via approved video telehealth [X] In-person examination Evidence review --------------- Was the Veteran's VA claims file reviewed? [X] Yes [ ] No If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: CPRS If no, check all records reviewed: [ ] Military service treatment records [ ] Military service personnel records [ ] Military enlistment examination [ ] Military separation examination [ ] Military post-deployment questionnaire [ ] Department of Defense Form 214 Separation Documents [ ] Veterans Health Administration medical records (VA treatment records) [ ] Civilian medical records [ ] Interviews with collateral witnesses (family and others who have known the Veteran before and after military service) [ ] No records were reviewed [ ] Other: 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with a heart condition? [X] Yes [ ] No [X] Coronary artery disease ICD code: 414.00 Date of diagnosis: 3/7/12 [X] Unstable angina ICD code: 413.9 Date of diagnosis: 3/7/12 2. Medical History ------------------ a. Describe the history (including onset and course) of the Veteran's heart condition(s) (brief summary): Patient sustained a non-ST elevation myocardial infraction on 3/5/12. Cardiac catheterization was completed on 3/7/12 which revealed multi-vessel coronary artery disease, to include complete blockage of RCA. He subsequently underwent drug-eluting stent placement to LAD and mid-LAD. On 4/20/12, patient had underwent an unsuccessful attempt at revascularization of the RCA and non-flow-limiting RCA dissection (in previously-occluded RCA segment). Over the next couple of years, patient continued to experience angina for which he has been taking isosorbide. On 1/30/14, patient underwent additional stent placement to the OM1. Cardiac catheterization on this date noted severe coronary artery disease, including CTO RCA and 70% mid OM 1. On 3/3/14, myocardial perfusion study showed reversible perfusion defect in the inferior and inferior lateral wall consistent with ischemia, in addition to a possible small mid anterior defect and noted left ventricular ejection fraction of 60%. On 5/16/14, patient had unsuccessful PTCA at Southern Arizona VA Health Care System. Exercise tolerance test completed on 7/14/14 indicated 7.6 METS. Miltary service: Navy 1998-2005. Current symptoms: Chest pain daily, with and without activity. Takes nitroglycerine one sublingual tablet daily as needed for chest pain. Pain is located mid sternum with radiation to left arm. May have intermittent nausea, jaw pain, and low back pain that accompanies chest pain. Three syncopal episodes in the last 12 mos, most recently in July 2014. Shortness with and without exertion. b. Do any of the Veteran's heart conditions qualify within the generally accepted medical definition of ischemic heart disease (IHD)? [X] Yes [ ] No If yes, list the conditions that qualify: Ischemic heart disease with unstable angina c. Provide the etiology, if known, of each of the Veteran's heart conditions, including the relationship/causality to other heart conditions, particularly the relationship/causality to the Veteran's IHD conditions, if any: Heart condition #1: Provide etiology Coronary artery disease. Etiology: Atherosclerosis Heart condition #2: Provide etiology Unstable angina: Etiology: Coronary artery disease d. Is continuous medication required for control of the Veteran's heart condition? [X] Yes [ ] No If yes, list medications required for the Veteran's heart condition (include name of medication and heart condition it is used for, such as atenolol for myocardial infarction or atrial fibrillation): Atorvastatin 40mg daily, clopidogrel 75mg daily, isosorbide 30mg ER daily, metoprolol 50mg ER daily, aspirin 81mg daily, nitroglycerin 0.4mg as needed for chest pain. 3. Myocardial infarction (MI) ----------------------------- Has the Veteran had a myocardial infarction (MI)? [X] Yes [ ] No MI #1: Date and treatment facility: San Diego VA Health Care System 3/7/12 4. Congestive Heart Failure (CHF) --------------------------------- Has the Veteran had congestive heart failure (CHF)? [ ] Yes [X] No 5. Arrhythmia ------------- Has the Veteran had a cardiac arrhythmia? [ ] Yes [X] No 6. Heart valve conditions ------------------------- Has the Veteran had a heart valve condition? [ ] Yes [X] No 7. Infectious heart conditions ------------------------------ Has the Veteran had any infectious cardiac conditions, including active valvular infection (including rheumatic heart disease), endocarditis, pericarditis or syphilitic heart disease? [ ] Yes [X] No 8. Pericardial adhesions ------------------------ Has the Veteran had pericardial adhesions? [ ] Yes [X] No 9. Procedures ------------- Has the Veteran had any non-surgical or surgical procedures for the treatment of a heart condition? [X] Yes [ ] No If yes, indicate the non-surgical or surgical procedures the Veteran has had for the treatment of heart conditions (check all that apply): [X] Percutaneous coronary intervention (PCI) (angioplasty) Indicate date of treatment or date of admission if admitted for treatment and treatment facility: 3/7/12 drug-eluting stent placement to LAD and mid-LAD. 4/20/12 unsuccessful attempt at revascularization of the RCA and non-flow-limiting RCA dissection (in previously-occluded RCA segment) 1/30/14 stent placement to the OM1 5/16/14 unsuccessful PTCA 10. Hospitalizations -------------------- Has the Veteran had any other hospitalizations for the treatment of heart conditions (other than for non-surgical and surgical procedures described above)? [X] Yes [ ] No a. Date of admission for treatment and treatment facility: 7/17/14, Long Beach VA b. Condition that resulted in the need for hospitalization: Admitted for chest pain/unstable angina 11. Physical exam ----------------- a. Heart rate: 68 b. Rhythm: [X] Regular [ ] Irregular c. Point of maximal impact: [X] Not palpable [ ] 4th intercostal space [ ] 5th intercostal space [ ] Other, specify: d. Heart sounds: [X] Normal [ ] Abnormal, specify: e. Jugular-venous distension: [ ] Yes [X] No f. Auscultation of the lungs: [X] Clear [ ] Bibasilar rales [ ] Other, describe: g. Peripheral pulses: Dorsalis pedis: [X] Normal [ ] Diminished [ ] Absent Posterior tibial: [X] Normal [ ] Diminished [ ] Absent h. Peripheral edema: Right lower extremity: [X] None [ ] Trace [ ] 1+ [ ] 2+ [ ] 3+ [ ] 4+ Left lower extremity: [X] None [ ] Trace [ ] 1+ [ ] 2+ [ ] 3+ [ ] 4+ i. Blood pressure: 132/78 12. Other pertinent physical findings, complications, conditions, signs and/or symptoms ----------------------------------------------------------------------- a. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis section above? [ ] Yes [X] No b. Does the Veteran have any other pertinent physical findings, complications, conditions, signs and/or symptoms related to any conditions listed in the Diagnosis section above? [ ] Yes [X] No 13. Diagnostic Testing ---------------------- a. Is there evidence of cardiac hypertrophy? [ ] Yes [X] No b. Is there evidence of cardiac dilatation? [ ] Yes [X] No c. Diagnostic tests [X] EKG Date of EKG: 5/16/14 Result: [X] Other, describe: Sinus rhythm with artifact, rate 86. [X] Chest x-ray Date of CXR: 7/18/14 Result: [X] Normal [ ] Abnormal, describe: [X] Echocardiogram Date of echocardiogram: 3/6/12 Left ventricular ejection fraction (LVEF): 67 % Wall motion: [X] Normal [ ] Abnormal, describe: Wall thickness: [X] Normal [ ] Abnormal, describe: [X] Coronary artery angiogram Date of angiogram: 1/30/14 Result: [ ] Normal [X] Abnormal, describe: Severe CAD, including CTO RCA, 70% mid OM 1, signficant by FFR, see full report below [X] Other test, specify: Myocardial perfusion scan Date: 3/3/14 Result: 1. The myocardial perfusion scan shows reversible perfusion defect in the inferior and inferior lateral wall consistent with ischemia also there was a possible small mid anterior defect. 2. The Left Ventricular ejection fraction is 60%. 14. METs Testing ---------------- Is there a medical contraindication for not performing METs testing? [ ] Yes [X] No a. [X] Exercise stress test Date of most recent exercise stress test: 7/14/14 Results: 1) Submaximal study 64% MPHR -target heart rate not achieved due to beta blocker use. 2) good functional capacity. 3) index chest pain noted during exam w/o significant ST changes. 4) overall, low cardiac risk. METs level the Veteran performed, if provided: 7.6 b. Interview-based METs test No response provided. c. If the Veteran has had both an exercise stress test and an interview-based METs test, indicate which results most accurately reflect the Veteran's current cardiac functional level: [ ] Exercise stress test [ ] Interview-based METs test [X] N/A d. Is the METs level limitation due solely to the heart condition(s)? [X] Yes [ ] No e. In addition to the heart condition(s), does the Veteran have other non-cardiac medical conditions (such as musculoskeletal or pulmonary conditions) limiting the METs level? [ ] Yes [X] No If yes, identify each condition and describe how each non-cardiac medical condition limits the Veteran's METs level: 15. Functional impact --------------------- Does the Veteran's heart condition(s) impact his or her ability to work? [X] Yes [ ] No If yes, describe impact of each of the Veteran's heart conditions, providing one or more examples: Unable to run, unable to walk greater than 200 meters, unable to lift greater than 100 lbs with 4 repetitions. 16. Remarks, if any ------------------- CPRS Reviewed: 3/6/12 Echocardiogram: ---------------------- Transthoracic Echocardiogram (3/6/12): LVEF 67% with inferior hypokinesis. Normal left ventricular diastolic function is observed. Valves are without any hemodynamically significant lesions. 3/7/12 CORONARY ANGIOGRAPHY: --------------------------- Summary: 2 vessel CAD Dominance: Right dominant Stenoses Details ----------------------------------------------------------------------- -------- Segment Stenosis* Characteristics and Comments ----------------------------------------------------------------------- -------- Left Main short LAD (overall) 85 sequential 70-85% narrowing in mid LAD with hazy appearance CIRCUMFLEX (overall) 1st Obtuse Marginal 60 large branching vessel, 50-60% lesion at distal bifurcation RCA (overall) 100 mid occluded with L to R collaterals ----------------------------------------------------------------------- -------- * Highest % Stenosis Within Segment FINAL DIAGNOSIS 2 Vessel CAD with critical stenosis in mid LAD and Occluded RCA Successful PCI of mid LAD distal to proximal (a) Xience 2.75 x 23mm - 18 atm (b) Xience 3.0 x 28mm - post dilated with 3.5 NC Quantum to 18atm -------------- PCI Lesion #1: Mid LAD -------------- Guide Catheter: EBU 4, 6 fr, good support Lesion Length: 40mm Risk Assessment: High Pre-Procedure Stenosis: 85%; TIMI Flow: 3 - Complete flow Post-Procedure Stenosis: 0%; TIMI Flow: 3 - Complete flow Treatment/Device Description ----------------------------------------------------------------------- ------- 1. Lesion Crossing BMW 300cm 2. Balloon OTW Sprinter 2 mm x 15 mm peak inflation pressure: 12 atm 3. Stent - DES Xience V 2.75 mm x 23 mm peak inflation pressure: 18 atm 4. Stent - DES Xience V 3 mm x 28 mm peak inflation pressure: 16 atm 5. Balloon NC Quantum 3.5 mm x 15 mm peak inflation pressure: 18 atm ----------------------------------------------------------------------- ------- PCI Lesion #2: Mid Circumflex Guide Catheter: EBU 4, 6 fr Treatment/Device Description ----------------------------------------------------------------------- ------- 1. Lesion Crossing BMW 300cm 2. Other IVUS BS Atlantis 40mHz 4/20/12 Cardiac Catheterization: ------------------------------- ANGIOGRAPHY showed following: Summary: 1 vessel CAD Dominance: Right dominant Segment Stenosis* Characteristics and Comments ----------------------------------------------------------------------- ------ Left Main Short, patent. LAD (overall) Patent previously placed stents in the mid -LAD. Provides L->R collaterals. CIRCUMFLEX (overall) Patent, with a large OM1 and thin OM2. Ongoing circumflex is small. Provides L->R collaterals. 1st Obtuse Marginal 50 Stenosis at the bifurcation of OM1 into two smaller vessels. RCA (overall) Mid-occlusion, unchanged from prior. Mid RCA 100 CTO FINAL DIAGNOSIS 1) Patent previously placed LAD stents, with remaining CAD of other vessels unchanged FINAL RESULTS 1) Unsuccessful attempt at revascularization of the RCA CTO, with non-flow-limiting RCA dissection (in previously-occluded RCA segment). 5/4/12 DISCHARGE SUMMARY ------------------------- DATE OF ADMISSION: May 4,2012 DATE OF DISCHARGE: May 5,2012 STAFF PHYSICIAN (Attending Physician): Dr. Hu HOUSESTAFF: Dr. Ashmi Doshi, R2. Dr. Adam Burgoyne, R1 CHIEF COMPLAINT: Chest pain PRINCIPAL DIAGNOSIS: Chest pain SECONDARY DIAGNOSES/COMPLICATIONS/COMORBIDITIES: CAD, HLD, Transaminitis 1/30/14 CORONARY ANGIOGRAPHY: ---------------------------- Native Vessels: Summary: 2 vessel CAD Dominance: Right dominant Stenoses Details ----------------------------------------------------------------------- -------- Segment Stenosis* Characteristics and Comments ----------------------------------------------------------------------- -------- Left Main Normal Proximal LAD Normal Mid LAD Luminal irregularities, stent is widely patent Distal LAD Normal Proximal Circumflex Normal Mid Circumflex Normal Distal Circumflex Normal 1st Obtuse Marginal 70 RCA (overall) CTO ----------------------------------------------------------------------- -------- * Highest % Stenosis Within Segment FEMORAL ANGIOGRAPHY sheath in CFA FRACTIONAL FLOW RESERVE/PRESSURE WIRE 0.79 across mid OM 1 MEDICATIONS Adenosine 0.4 mg iv, Given during visit, Regadenoson Bivalirudin wt adjusted, Given during visit Fentanyl 50 mcg iv, Given during visit Midazolam 3 mg iv, Given during visit Summary Data: Total Contrast: 130 mL, Ultravist (iopromide) Total Fluoroscopy Time: 8 min Total Radiation Dose: 963 Gy-cm*2 Total Fluids: 150 mL Estimated Blood Loss: 5 mL COMPLICATIONS IN LAB No Complications FINAL DIAGNOSIS 1. Severe CAD, including CTO RCA, 70% mid OM 1, signficant by FFR RECOMMENDATIONS 1. PCI to OM 1 2. Myocardial stress/viability by nuclear to assess inferior wall ischemia. If positive then would consider CTO PCI as staged. 3/3/14 Myocardial perfusion scan: -------------------------------- Gated SPECT stress images demonstrate that the left ventricular ejection fraction was calculated to be approximately 68 %, >50% is normal. The wall motion and wall thickening were normal. The end systolic volume was 52 ml, < 70 ml is normal. Gated SPECT rest images demonstrate that the left ventricular ejection fraction was calculated to be approximately 60 %, >50% is normal. The wall motion and wall thickening were normal. The end systolic volume was 43 ml, < 70 ml is normal. The perfusion images show reversible inferior and inferior lateral perfusion defect at the mid and basal segments also there was a possible small mid anterior reversal defect. The summed stress score was 9 (summed stress score >13 is severely abnormal, 8-13 moderately abnormal, 5-8 mildly abnormal and 3 or less is normal) This was done using the 17 segment method. Summed Stress Score (SSS) Event Rate % Percent L.V. myocardium MI rate Cardiac Death rate - Normal (SSS <3) ............................... 0.5 .......................... 0.3 - Mild (SSS 4-8) ............................. ......2.7 .......................... 0.8 - Moderate (SSS 9-15) .........................2.9 .......................... 2.3 - Severe (SSS >15) ......................... ....4.2 .......................... 2.9 Summed rest score was 4 T.i.d. ratio 0.94, normal is <1.23 Impression: 1. The myocardial perfusion scan shows reversible perfusion defect in the inferior and inferior lateral wall consistent with ischemia also there was a possible small mid anterior defect. 2. The Left Ventricular ejection fraction is 60%. 5/16/14 PERCUTANEOUS CORONARY INTERVENTION REPORT: Procedures: PCI, Femoral Angiography: ----------------------------------------------------------------------- ----------------- Status: Elective - staged PCI This was an outpatient procedure. NPO status greater than 4 hours verified. Type of procedure, site, and patient ID were verified with the patient. Re-assessment was performed immediately prior to conscious sedation and no change was noted. Indications: Stable Angina ACCESS Primary Arterial: Right Femoral, 6F Sheath, Seal closure INTERVENTIONS -------------- PCI Lesion #1: Mid RCA -------------- Guide Catheter: JR 4, 6 fr Lesion Length: 20mm Characteristics: CTO Risk Assessment: High Pre-Procedure Stenosis: 100%; TIMI Flow: 1 - Slow penetration Post-Procedure Stenosis: 100%; TIMI Flow: 1 - Slow penetration Treatment/Device Description ----------------------------------------------------------------------- ------- 1. Balloon Sprinter 1.25 mm uanble to cross with balloon, wire had some penetration of the cap ----------------------------------------------------------------------- ------- FEMORAL ANGIOGRAPHY sheath in CFA MEDICATIONS Bivalirudin, Given during visit Diphenhydramine 25 mg iv, Given during visit Fentanyl 25 mcg iv, Given during visit Midazolam 3 mg iv, Given during visit Summary Data (PCI only totals): Total Contrast: 57 mL Total Fluoroscopy Time: 11 min Total Radiation Dose: 543 Gy-cm*2 Total Fluids: 100 mL Estimated Blood Loss: 5 mL COMPLICATIONS IN LAB No Complications FINAL RESULTS 1. Unable to cross with balloon (1.25 mm), wire did penetrate proximal cap. FINAL RECOMMENDATIONS 1. Aggressive antinaginal therapy/optimize medical therapy. 7/15/14 Cardiology Note: ----------------------- "NYHA: [] Class I (No limitation of physical activity) [] Class II (Slight limitation of physical activity) [x] Class III (Marked limitation of physical activity) [] Class IV (Unable to do any physical activity without symptoms) ACC / AHA STAGES: [] Stage A [x] Stage B [] Stage C [] Stage D Estimation of LV Ejection Fraction: [x] LV function unknown [] LVEF normal or near normal [] LVEF 35-55%