hypertension C & P For Ihd

[navy_619]

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%

[Berta]

"An error occurred

You do not have permission to reply to this topic."


The topic was:http://www.hadit.com/forums/topic/58304-ihd-c-p/

and I tried to post:


"Do you have a nexus to the heart disease in your service records?

Did you file this claim within one year after your discharge?

Prior to March 2012 did the VA give you medical care?"

[navy_619]

Yes ma'am

Edited September 22, 2014 by navy_619 (see edit history)

[navy_619]

"An error occurred

You do not have permission to reply to this topic."

The topic was:http://www.hadit.com/forums/topic/58304-ihd-c-p/

and I tried to post:

"Do you have a nexus to the heart disease in your service records?

Did you file this claim within one year after your discharge?

Prior to March 2012 did the VA give you medical care?"

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.

[Chuck75]

A LVEF of 60% is higher than I'd expect, given the other symptoms.

The same is true of the METS rating. As to taking treadmill tests - -

The last time I took one was in the late 80's, and it precipitated a mild heart attack.

After a heart cath, I was sent to Emory for open heart surgery with multiple bi-passes.

Stents weren't an option in those days.

If stents do the job, believe me, that's preferable to the side effects of open heart surgery.

I will say that open heart surgery can produce superior results to stinting, particularly .

at a young age of 33.

I'd second the opinions that a veteran is better off obtaining heart related

care from outside the VA. One of my previous neighbors had heart problems in the late 80's, and open heart surgery

from the VA. Only one bi-pass was put in place, and the general medical opinion was that multiple bi-passes were needed.

The excuse? Seems that the operating room scheduling had no flexibility, and it was "inconvenient" to take the time to do things properly.

In my claim, due to the medical records, the VA did not require a C&P. They tried to schedule one, but

the medical records and documentation along with VA standard policy precluded such things as a treadmill test,

and the VA did not want to spring for the more expensive alternatives. The supposedly "gold standard" for measurement

of such things is a heart cath and various readings of pressure, rates, and "waveforms" inside and outside the heart.

I had that done when stints were placed, and prior to the VA trying to schedule a treadmill test.

Not to mention that the Nehmer Review Board's writeup sort of took the RO to task for forcing me to go to it for approval.

Something about the evidence being sufficient for a direct service award, although Nehmer went ahead and granted presumptive.

The VA is still largely ignoring the provisions in the laws relating to relaxed evidentiary standards for "combat veterans", and attempting to negate them whenever possible.

The BVA and the courts try to discount the provisions whenever they can. As far as I could tell, this has been going on for multiple decades.

When I had no choice but to get involved with the VA in "modern times", they were still fighting cases going back to the Korean war and the Chosen Reservoir battle.

Edited September 24, 2014 by Chuck75 (see edit history)

[georgiapapa]

navy_619,

From reading your post, it appears you are receiving your cardiac care through the VA healthcare system. Is the VA healthcare system your only option? A lot of members on this website, including myself, recommend using private healthcare providers for any medical conditions (CAD, cancer, etc.) that could be life threatening.

I currently have IHD/CAD with 3 stents and a pacemaker. I also have cancer (multiple myeloma). The VA healthcare system would be a last resort for treatment for my cardiac condition or my cancer. Fortunately I am old enough for medicare and also have private health insurance so I use private healthcare providers.

I hope you have other options. If you do, I hope you seriously consider those other options. If you don't, I hope you get decent care at the VA. Most important, I hope you receive timely care at the VA. If not, complain until you do. You deserve quality health care in a timely manner. Don't get short changed.

Good luck to you and thank you for your service.

[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...