Carlie, Could You Please Take A Look At This

[bm6546]

Carlie,

I would appreciate it if you would please look at this and tell me what you think. I know you deal a lot with claims that involve a CUE.

I would like your take on this.

Thanks in advance,

Brian

[bm6546]

Back in 2008 the VA Cardiologist prescribed me with Metropolol Tartrate because my PAT was getting worse. Metropolol Tartrate is used to treat various heart tachycardia arrythmias and anxiety. It seems to be working because my PAT attacks have decreased somewhat. My anxiety seems to be a little better also.

In my experiences as a mental health provider (and patient), it would be almost impossible to rule out an anxiety disorder as primary or secondary to the PAT. In other words, I would give the benefit of the doubt to the veteran that the PAT had it's onset in the military service as evidenced by objective, measurable criteria --and the PAT has in fact incresesed in severity. The PAT is iniextricably linked to the anxiety disorder --and both may have contributed to his additional heart disease. This link however, is totally out of my range of expertise.

Hoppy, This is an excellent post. As ever, your sensibilities are grossly intact ;-)

Indeed, it is intimidating when the VA decides "existed prior to service (EPTS)". Your position here illustratues the VA history (sans court documents) of denying claims based upon the "veterans unsupported statements" --that his/her disease or illness EPTS.

Federals Law, Title 38, has ruled that (in most cases) the veteran is not capable of providing expert medical testimony; the veteran must support his medical claim with medical evidence. Likewise, the VA can not deny a claim sans medical evidence. The VA's opinon must be supported with medical evidence.

My intution about this specific claim is that PAT is evidenced by objective (measurable) medical criteria. Thus, the condition remains service-connected, even at 0% --and this veteran has been service-connected for PAT more than 20 years! The VA can not severe service-connection, itis protected by law.

In addition, PAT also has a subjective element --and is both caused by anxiety, as well as causing anxiety. Intertwined. The veteran has filed a claim for an anxiety disorder. There are many roads to service-connection ...

In my experiences as a mental health provider (and patient), it would be almost impossible to rule out an anxiety disorder as primary or secondary to the PAT. In other words, I would give the benefit of the doubt to the veteran that the PAT had it's onset in the military service as evidenced by objective, measurable criteria --and the PAT has in fact incresesed in severity. The PAT is iniextricably linked to the anxiety disorder --and both may have contributed to his additional heart disease. This link however, is totally out of my range of expertise.

The VA's rating decision to reduce compensation from 10% to to 0% was thoughtless, unkind and also erroneous --because the criteria used to severe compensation was based uopn the veteran's unsupported medical "opinion".

I very much dislike the VCAA in that is eliminated the proactive approach to the veteran seeking the NEXUS STATEMENT from a medical doctor ... more on that later. ~Wings

[Wings]

Back in 2008 the VA Cardiologist prescribed me with Metropolol Tartrate because my PAT was getting worse. Metropolol Tartrate is used to treat various heart tachycardia arrythmias and anxiety. It seems to be working because my PAT attacks have decreased somewhat. My anxiety seems to be a little better also.

In my experiences as a mental health provider (and patient), it would be almost impossible to rule out an anxiety disorder as primary or secondary to the PAT. In other words, I would give the benefit of the doubt to the veteran that the PAT had it's onset in the military service as evidenced by objective, measurable criteria --and the PAT has in fact incresesed in severity. The PAT is iniextricably linked to the anxiety disorder --and both may have contributed to his additional heart disease. This link however, is totally out of my range of expertise.

Good, good, all good.

I am forgetting: has the BVA addressed all of your claims x3 (increase in SC PAT? New claim for Anxiety? CUE?)

I need to go back and read what the BVA told the RO to do. ~Wings

[Hoppy]

Wings,

We are on the same wave length. My next post was to ask questions to figure out what has been denied, what has been closed, what is on remand etc.

[Hoppy]

BM6546,

This issue may never come up. However,to show you how I think as an advocate I will dig into this a little.

If you told the military doctors you were aware of your heart fluttering and skipping beats they could justify pre-service onset if they assumed that you in fact having a fluttering heart that was skipping beats.

The laws have wiggle room. Even though they are not supposed to use a veterans subjective statements it is possible that the veteran could give such a detailed picture in their descriptions of pre service episodes that there would be no other explanation. I do not believe your condition gives rise to the "no other explanation" scenario.

The question I have as an advocate is how do you really know that you were not having feelings similar to fluttering or skipping beats. Were you actually experiencing deep muscle twitches in your chest? There is actually a ton of information on the web identifying the confusion between muscle twitches and heat flutter.

Do your service records state how you were checking your pulse prior to the military. I was taught that using your wrist was not as reliable as your carotid artery. If your SMR is silent for how you were testing yourself prior to the military I would argue that your statement back then were not sufficiently developed to determine the reliability of your statements at that time. Any attempt to determine today as to what was going on in 1968 based on your recollection would be challenged due to the fact that there would need to be some way to determine the reliability of 40 year old memories.

The fact that you only mentioned flutter and skipping beats and did not say anything about accelerated heart rate makes me wonder what was really going on. Accelerated heart rate measured reliably would be the key marker for all forms of PAT.

________________________________________________________________

http://www.docofdiets.com/exercise-3.htm

How do you check your pulse? The best way to check your pulse during exercise is not at your wrist like you have seen doctors and nurses do on television. The best and most accurate place to check your pulse druing exercise is by placing your index and middle fingers gently over the carotid artery in your neck.

_____________________________________________________________

Check out this conversation I found on a med site.

Question

Aug 24, 2004

Hi im 19 years old and im not sure if i feel the same sensations but i do infact feel like there is something vibrating when i hit my chest or sometimes it can happen out of the blue.

When these sensations happen i check my pulse and its normal, doesnt mean its my heart right? more like muscle spasms?

Response

Aug 25, 2004

Internal sensations of vibrations can be causedby a wide range of phenomenon. Muscle spasms could only come from muscles, and there are only a few inside the chest: heart, esophagus, diaphragm and artery walls. If there is no arrhythmia, then it's likely coming from one of the other sources.

On the other hand, if you experience an "internal" sensation ofvibration "out of the blue", then my prime suspect would be the diaphragm, as it has a history of reacting to exercise-induced stress at later time points, thus seeming to come out of the blue. Check out the neurologyforum for examples of muscular ticks and spasms. Again, this is generally not abig deal, as it may arise due to anxiety as well.<br style="mso-special-character: line-break;"><br style="mso-special-character: line-break;">

Edited December 5, 2011 by Hoppy

[bm6546]

Sorry, I screwed up the last reply.

The BVA has remanded:

1. Entitlement to an increased compensable evaluation for a heart disorder, to include paroxysmal atrial tachycardia (PAT).

2. Entitlement to a total disability rating based on individual unemployability.

The RO has already denied my Anxiety. There has been nothing mentioned about the CUE in the remand.

Good, good, all good.

I am forgetting: has the BVA addressed all of your claims x3 (increase in SC PAT? New claim for Anxiety? CUE?)

I need to go back and read what the BVA told the RO to do. ~Wings

[bm6546]

When I was inducted in the Navy, I think I recall the doctor asking me about my heart problem. I believe I told them that I was in good health and that I had "occasional" heart pounding and that it was not incapacitating. That all changed, of course, once I was in the service with all the exercise and drilling. I did feel that at the time of enlistment that I was in pretty good shape, as any 18 year old would be.

I don't believe that before I went in the service that I ever checked my pulse, not sure if I even knew how to check it back then. I do remember the doctors in the hospital did show me how to check my pulse with my fingers on my wrist. And they also showed me how to put my head down between my knees to help slow down my racing heart. And again, I repeat, I was never treated by any doctors for my PAT before I entered the service. There are no medical records anywhere that I was seen or treated for any heart problems I may or may not have had.

The more I think about this, I am not even sure if I did in fact, have this heart problem before I enlisted in the Navy. I know my records state that I have been having this problem most of my life. I am just not sure of this at all. I know I saw a lot of doctors while in the Navy and just not sure of what I did or did not say to them.

BM6546,

This issue may never come up. However,to show you how I think as an advocate I will dig into this a little.

If you told the military doctors you were aware of your heart fluttering and skipping beats they could justify pre-service onset if they assumed that you in fact having a fluttering heart that was skipping beats.

The laws have wiggle room. Even though they are not supposed to use a veterans subjective statements it is possible that the veteran could give such a detailed picture in their descriptions of pre service episodes that there would be no other explanation. I do not believe your condition gives rise to the "no other explanation" scenario.

The question I have as an advocate is how do you really know that you were not having feelings similar to fluttering or skipping beats. Were you actually experiencing deep muscle twitches in your chest? There is actually a ton of information on the web identifying the confusion between muscle twitches and heat flutter.

Do your service records state how you were checking your pulse prior to the military. I was taught that using your wrist was not as reliable as your carotid artery. If your SMR is silent for how you were testing yourself prior to the military I would argue that your statement back then were not sufficiently developed to determine the reliability of your statements at that time. Any attempt to determine today as to what was going on in 1968 based on your recollection would be challenged due to the fact that there would need to be some way to determine the reliability of 40 year old memories.

The fact that you only mentioned flutter and skipping beats and did not say anything about accelerated heart rate makes me wonder what was really going on. Accelerated heart rate measured reliably would be the key marker for all forms of PAT.

________________________________________________________________

http://www.docofdiets.com/exercise-3.htm

How do you check your pulse? The best way to check your pulse during exercise is not at your wrist like you have seen doctors and nurses do on television. The best and most accurate place to check your pulse druing exercise is by placing your index and middle fingers gently over the carotid artery in your neck.

_____________________________________________________________

Check out this conversation I found on a med site.

Question

Aug 24, 2004

Hi im 19 years old and im not sure if i feel the same sensations but i do infact feel like there is something vibrating when i hit my chest or sometimes it can happen out of the blue.

When these sensations happen i check my pulse and its normal, doesnt mean its my heart right? more like muscle spasms?

Response

Aug 25, 2004

Internal sensations of vibrations can be causedby a wide range of phenomenon. Muscle spasms could only come from muscles, and there are only a few inside the chest: heart, esophagus, diaphragm and artery walls. If there is no arrhythmia, then it's likely coming from one of the other sources.

On the other hand, if you experience an "internal" sensation ofvibration "out of the blue", then my prime suspect would be the diaphragm, as it has a history of reacting to exercise-induced stress at later time points, thus seeming to come out of the blue. Check out the neurologyforum for examples of muscular ticks and spasms. Again, this is generally not abig deal, as it may arise due to anxiety as well.<br style="mso-special-character: line-break;"><br style="mso-special-character: line-break;">