Ischemic Heart Disease

[georgiapapa]

Up until a couple of days ago, I never thought I had any heart problems other than a mitral valve prolapse. Earlier this week I had been to my private primary care doctor for a cough and intermittent chest pain. I had undergone a stress test and an echo of my heart in July by my cardiologist and was told everything looked fine so I did not think my recent chest pains were caused by heart problems. My pcp did a chest x-ray and EKG and said it wasn't my heart and he diagnosed me with pleurisy and bronchitis.

Wednesday night of this week I started experiencing severe chest pains and my wife called 911. I took an ambulance trip to the emergency room. After running some blood tests, I was told my cardiac enzymes were elevated and the cardiologist performed a heart cath. After the heart cath, the cardiologist informed me she had placed two stents in my heart due to a 99% blockage in one part of my LCD and 80% blockage in another part of my LCD. I believe the LCD she was referring to is the left anterior descending artery of my heart. My cardiologist advised that I did not have a heart attack but she said I was on the verge of a serious heart attack prior to placement of the stents. I am currently in the heart unit of my local hospital but I hope to be discharged this morning.

I am totally lost as to what I need to do in regards to a claim for AO related IHD. I am a boots on the ground Vietnam veteran so I think I would qualify under the AO presumptive policy. Any guidance anyone can give as to what is needed and how to proceed at this point in time would be appreciated. Even if I would be rated at 0% service connected (since I did not experience a heart attack), at least this would make benefits available to my wife in the event I later had a fatal heart attack. Your thoughts ans suggestions would be appreciated.

Georgiapapa...

[stillhere]

Berta just hit on something we all with high choelesteral and just about anyone. Get a copy of your blood work when you have it and do what I have been doing for a while. Whenever I go for an appointment with my PCP I have her bring up my latest blood work and go over it with her. That way I understand it better and any kind of lows or highs can be addressed.

My advise to you since you have just had an event is to get with your doctor and look at the blood work you had done before and the one you had done after.See if there is anything there A. you need to keep an eye on and B. things that my have been missed so you can be aware of those too.

Good luck to you and remember always listen to your body especially now that you are aware you have a problem!

Stillhere

Edited September 16, 2012 by stillhere

[SP4RVN1971]

Berta,

I talked with my cardiologist and asked why there was no indication of blockages during my diagnostic tests in July. She seemed truly concerned and said she was going to look into the matter because there should have been some red flags. Apparently, her cardiology group has someone who reviews the tests for the cardiologists and prepares reports of their findings for them. I am not sure of the professional background of the person performing the reviews.

I advised my cardiologist that I was concerned about the reliability of the echo and ECG versus the cath procedure. She told me that an ECG and echo have an important role in diagnosing cardiac problems but are not as reliable as other diagnostic tests in situations such as mine. My cardiologist characterized my blocked artery symptoms as "atypical" because the only symptom I experienced on the night I went to the emergency room was a sharp stabbing pain in the center of my chest. I did not have any pain radiating to other parts of my body, no profuse sweating, no crushing feeling in the center of my chest, etc. Due to my lack of the standard symptoms, my cardiologist instructed me to contact her immediately if I experience any severe chest pains in the future and she will call the hospital and schedule me for a cath procedure upon my arrival in the emergency room.

Georgiapapa...

Georgiapapa, My conditions is simular to your's. Most of the time in the day time. if I was at rest my chest would start to have sharp pain in the center of my chest. If I was moving around It was less. At night time in the mid of the night it would increase. Of course I have Hot Flashes from the cancer medicine, so it is hard to tell about sweating??? The EKG's mostly - only work if you have heart damage and as long you are getting some blood to that part of your heart like in my case 85% bockage the EKG won't show a problem.

[georgiapapa]

My thanks to all of you for your informative replies.

I need some additional guidance from all of you in regards to filing my claim for AO IHD considering the fact that I have a current claim pending for AO Multiple Myeloma and Peripheral Neuropathy secondary to my Multiple Myeloma. I had my C & P for MM and PN on September 12th. Since I am past the C & P process, I do not want to do anything to delay my current claim but I also want to establish the earliest possible effective date on my IHD claim.

I planned to ask my cardiologist to complete a DBQ during my follow up visit with her on September 20th.

I am also considering filing my AO IHD claim through the fast track process.

Question: Do you think filing my AO IHD claim before resolution of my MM & PN claim will delay my claim for MM & PN?

Question: If you believe it may delay my claim, how do I protect myself as to the earliest effective date for my AO IHD claim?

Question: How is the earliest effective date established in an IHD claim? (Is it based on the date claim received, date symptoms recorded in medical records, date my stents were installed or what?)

Question: As to the fast track process, are there any drawbacks to using this process?

Question: If I use the fast track process, how is the DBQ submitted?

All info provided is sincerely appreciated.

Georgiapapa...

[SP4RVN1971]

Georgiapapa,

Back in 04/2010 I filed for the AO for PC, DMII only.

VA had seem from medical records that I had IHD and at 12/2010 I got 10% for secondary to DMII.

On 04/2011 I got compensated for AO for PC, DMII, and long with PN in both legs secondary to DMII and Lypmh Node cancer

The answer I think is to file for the IHD, because you will probably get some form of compensation earlier while the other conditions grind

thru the VA machine.

Later I got all the other conditions on 12/2011 and P&T 100% on 01/2012

Edited September 16, 2012 by SP4RVN1971

[georgiapapa]

Berta and others,

Today I obtained copies of some of my medical records from my cardiologist's office including the records for my July 2012 diagnostic tests and September 2012 records of my recent heart cath and stent placement. I have an appointment this Thursday September 20th with my cardiologist where I will have a lot of questions. Below is some of the comments found in the various reports:

July 10, 2012 Reports:

MYOCARDIAL SCAN (Lexican/Thalium stress test) "There are no areas of ischemia or scar tissue seen." IMPRESSION: "Normal myocardial scan. No change from the prior exam of 11/09/10."

EJECTION FRACTION: "The ejection fraction is calculated at 74%."

LEFT VENTRICULAR WALL MOTION: "Left ventricular wall contractility is noted to be normal with no areas of hypokinesis or akinesis. There is no paradoxical wall motion seen to suggest left ventricular wall aneurysm.."

IMPRESSION: "Normal left ventricular wall motion."

NOTE: This report is signed by a local radiologist.

LEXISCAN WORKSHEET (Screening for IHD) CLINICAL INFORMATION: "Patient with DOE/Fatigue and history of hypertension, hyperlipidemia." INTERPRETATION: "Resting electrocardiogram reveals sinus bradycardia at 51 bpm with a resting blood pressure of 128/64 mmHg. The patient received IV Lexiscan per protocol. Maximum increase in heart rate to approximately 100 bpm. There was quite a bit of artifact during the completion of the Lexiscan. Minimum drop in systolic blood pressure was to 90/60 mmHg. No significant ST changes were noted above the baseline abnormality when adjusting for the artifact intervening. No chest pain was experienced." CONCLUSION: "Nondiagnostic electrocardiographic response to IV Lexiscan." "Pharmacologic effect achieved." "Isotope study to follow." NOTE: This worksheet is signed by my cardiologist.

ECHOCARDIOGRAM - INDICATION: " sob, cp, htn, dizziness." LEFT VENTRICULAR STRUCTURE: "Normal in size and shape." LEFT VENTRICULAR FUNCTION: "Ejection fraction is estimated at 60-65%. No regional wall motion abnormalities were noted." LV DIASTOLIC FUNCTION: "Abnormal diastolic function with impaired relaxation." RV STRUCTURE & FUNCTION: "Size and function are normal." LA STRUCTURE: "Left atrium is mildly enlarged." RA STRUCTURE: "Right atrium is mildly enlarged." INTERATRIAL SEPTUM STRUCTURE: "Not well visualized." MV STRUCTURE & FUNCTION: "Mitral valve is mildly thickened." "Mild regurgitation." AV STRUCTURE & FUNCTION: "Aortic Valve is a tri-leaflet structure." "Aortic valve leaflets are thickened." TV STRUCTURE & FUNCTION: "Triscupid valve is structurally normal." "Mild tricuspid regurgitation." "Estimated right ventricular systolic pressure is 32mmHg." PV STRUCTURE & FUNCTION: "Pulmonic valve is structurally normally without stenosis or regurgitation." AORTA STRUCTURE: "Aortic root is normal." PERICARDIUM: "Percardium is normal." MISC. ITEMS: "Inferior vena cava is not well visualized." CONCLUSIONS: "Technically good, valvular sclerosis, mild triscupid and mitral regurgitation, diastolic dysfunction, biatrial enlargement." NOTE: This report is signed by my cardiologist.

September 13-15, 2012 Reports Regarding Placement of Stents:

PROCEDURE: "Left heart catheterization, selective coronary angiography, left ventriculogram, drug-eluting stent x 2 to the LAD, intercoronary nitroglycerin complex." ANGIOGRAPHY: "Left main coronary arter has ostial 20% disease." "Left anterior descending artery has a medially located moderate diagonal branch that has ostial 20% disease." "At this level the LAD has a very complex lesion that is 95-99% stenosed with what appears to be some thrombus." "The lesion is approximately 18-19 mm in length." "There is then a second diagnonal that is small to moderate size with a more tubular eccentric 70-80% stenoses in the distal LAD that is approximately 11 mm in size." "There is TIMI 2 flow." The circumflex is a large dominant system." There is a small first and second marginal." There is 20% luminal irregularities in the AV groove." There is a large distal posterolateral marginal and then there is 40% to 50% disease in the proximal segment of a large PDA>" "The right coronary artery is small and dominal." "There is proximal 20% disease." LEFT VENTRICULOGRAM: "Left ventriculogram in the RAO projection." "Three aortic valve cusps are present." Left ventricular systolic function is normal." "Ejection fraction estimated at 55%." "The apex is sluggish with some jypokinesis."

CONCLUSION: "Three-vessel coronary artery disease is significant in the LAD distribution representing the culprit." "Successful drug-eluting stent to proximal portion of distal LAD and mid LAD restoring TIMI 3 flow." "Preserved left ventricular systolic function with segmental abnormality."

NOTE: This report is signed by my cardiologist.

PATIENT HISTORY: "Hypertension, mitral valve prolapse, dyslipidemia, chronic fatigue, obstructive sleep apnea with CPAP, elevated cholesterol, elevated triglycerides, elevated LFTs, elevated bilirubin, plasma cell dyscrasia, GERD, Gastric polyps, iron deficiency anemia, testosterone deficiency, colon polyps.

Question: If the VA relies on METS & ejection fraction so much in their rating criteria, is there any chance I will be rated above 0% with my latest ejection fraction at 55%?

I will ask my cardiologist on Thursday about a METS score.

Please give me your thoughts and input as to what my reports indicate, especially the reports from September 2012 and your thoughts on a possible disability rating for IHD.

Thanks...Georgiapapa

[Berta]

This is the VA Schedule ofRatings criteria for ID (Diagnostic code 7005)

7005 Arteriosclerotic heart disease (Coronary artery disease):

With documented coronary artery disease resulting in:

Chronic congestive heart failure, or; workload of 3 METs or less results

in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular

dysfunction with an ejection fraction of less than 30 percent.......................... 100

More than one episode of acute congestive heart failure in the past year,

or; workload of greater than 3 METs but not greater than 5 METs

results in dyspnea, fatigue, angina, dizziness, or syncope, or; left

ventricular dysfunction with an ejection fraction of 30 to 50 percent............... 60

Workload of greater than 5 METs but not greater than 7 METs results

in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of

cardiac hypertrophy or dilatation on electrocardiogram,

echocardiogram, or X-ray................................................................................... 30

Workload of greater than 7 METs but not greater than 10 METs results

in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous

medication required............................................................................................ 10

"At this level the LAD has a very complex lesion that is 95-99% stenosed with what appears to be some thrombus."

I assume that due to this complex lesion, it probably would not have showed up on the ECHO.

Your documents here reveal some key points.

The 'some thrombus ' entry for example.

Thrombosis is usually what we call a clot.

The ECHO my husband had specifically stated 'no clots found in this study' as the thrombotic clot from his heart had already caused him to have a major brainstroke weeks prior to the ECHO.I assumed that tyour ECHO could have ruled out more thrombosis. Or revealed 'some thrombosis' but it didnt.

Your med recs here revealed something else Very significant.

Not only are your cholesterol levels high and I assume they are being medicated, but you listed that you have anemia.

Have you been diagnosed with thrombotic thrombocytopenic purura,sometimes called thrombocytopenia?

There is also association between Iron deficiency anemia and thrombocytopenia.

These meds can also contribute to formation of thrombosis:ticlopidine, clopidogrel, cyclosporine A, chemotherapy, and hormone replacement therapy and estrogens.

I am not a doctor but know more about heart disease then I ever dreamed I would know.

Many of us here know specific disabilities in and out.

I am only opining on what I read and I see other points in these med recs ,such as the different ejection fractions, and this makes it difficult to know what one the VA will interpret, probably they will use the most recent EF estimate.

I certainly don't see this as any Sec 1151 negligence issue,because your doctor is willing to find the cause of your problems.

But there are definitely things here that concern me and call for preventive measures, in my lay non medical opinion.

Measures which are probably being taken by your doctor already.

Are these cardiologists who signed the reports the same person?

I cant tell yet -are these VA cardiologists or private docs?

The test results don't seem to read like the VA's way of writing a narrative for these types of medical tests, and this is why I ask.

I regret I am asking something else that you probably already answered here.

Have you been diagnosed with Diabetes too or has that been ruled out?

Did you have chemo for the myeloma? It could be a factor in the evidence of some thrombosis, whoch I assume was the prime cause of the difficulties that brought you to the ER.

Why does this not state your multiple myeloma diagnosis?

"PATIENT HISTORY: "Hypertension, mitral valve prolapse, dyslipidemia, chronic fatigue, obstructive sleep apnea with CPAP, elevated cholesterol, elevated triglycerides, elevated LFTs, elevated bilirubin, plasma cell dyscrasia, GERD, Gastric polyps, iron deficiency anemia, testosterone deficiency, colon polyps."

These are all things your doctor will consider I am sure.