hypertension SECONDARY CONDITION OF SERVICE CONNECTED CONDITION

[VAW-126]

Can anyone tell me if Obstructive Sleep Apnea and Hypertension be secondary to CAD. Also the C&P examiner copied and pasted into my Heart Condition DBQ the following statements from my last cardiology exam. .

CC: 1st visit today. Pt w/ h/o chronic, stable angina - reported CP in service in 9/1990 - had NL MPI.  Has undergone heart CATHs (1993, 2008), which were NL except as noted below - advised he likely his microvascular disease, or microspasm, or (cardiac) syndrome X (decreased blood flow in LAD). Info in scanned records.

Pt has noted intermittent CP >25 years - avg 3x per month - occurs at rest or during sleep or w/ activity - pausing/resting typically relieves - uses one SL Nitro tab on avg of 1x per month to relieve CP.

The C&P examiner used the above cardiology exam as a Interview-based METs test because the limitation in METs level is due to multiple medical conditions including the heart condition, it is not possible to accurately estimate the percent of METs limitation attributable to each medical condition.

Based on the above statements from the Cardiologist could my SC heart condition be increased from 10% to 100%.

i. was also hospitalized in Dec 2016 for my heart condition in which a ECHO and Nuclear Stress Test was performed. My stress test showed I have a EF of 60%. But my ECHO revealed that I have the following:

Left Ventricular Basal Septal Hypertrophy, Left Ventricular Diastolic function abnormality with Mild (grade 1) showing impaired relaxation and Trace Mitral and Valve Regurgitation.

I also have a history of a past Myocardial Infarction when I was on active duty.

[FMFDOC25]

On 4/6/2017 at 2:20 PM, VAW-126 said:

Can anyone tell me if Obstructive Sleep Apnea and Hypertension be secondary to CAD. Also the C&P examiner copied and pasted into my Heart Condition DBQ the following statements from my last cardiology exam. .

CC: 1st visit today. Pt w/ h/o chronic, stable angina - reported CP in service in 9/1990 - had NL MPI.  Has undergone heart CATHs (1993, 2008), which were NL except as noted below - advised he likely his microvascular disease, or microspasm, or (cardiac) syndrome X (decreased blood flow in LAD). Info in scanned records.

Pt has noted intermittent CP >25 years - avg 3x per month - occurs at rest or during sleep or w/ activity - pausing/resting typically relieves - uses one SL Nitro tab on avg of 1x per month to relieve CP.

The C&P examiner used the above cardiology exam as a Interview-based METs test because the limitation in METs level is due to multiple medical conditions including the heart condition, it is not possible to accurately estimate the percent of METs limitation attributable to each medical condition.

Based on the above statements from the Cardiologist could my SC heart condition be increased from 10% to 100%.

i. was also hospitalized in Dec 2016 for my heart condition in which a ECHO and Nuclear Stress Test was performed. My stress test showed I have a EF of 60%. But my ECHO revealed that I have the following:

Left Ventricular Basal Septal Hypertrophy, Left Ventricular Diastolic function abnormality with Mild (grade 1) showing impaired relaxation and Trace Mitral and Valve Regurgitation.

I also have a history of a past Myocardial Infarction when I was on active duty.

Since you alluded to having 10% service-connected CAD: Sleep Apnea and Hypertension would be secondary conditons that can boost your disability rating depending on your medical history and medical evidence. SEE REQUIREMENTS FOR SECONDARY SERVICE CONNECTION TOWARDS THE END OF THIS POST.

If you have been diagnosed with OSA and are using a CPAP machine. The answer to part of your question is yes; Sleep Apnea is associated to or linked to Coronary Artery Disease.  Claim it  "Obstructive Sleep Apnea as Secondary to Coronary Artery Disease. If granted, Obstructive Sleep Apnea will be rated at 50%.

Here is a study that finds sleep apnea common in patients with coronary artery disease.

Wien Med Wochenschr. 2010 Jul;160(13-14):349-55. doi: 10.1007/s10354-009-0737-x.
Sleep apnea is common in patients with coronary artery disease.
Prinz C1, Bitter T, Piper C, Horstkotte D, Faber L, Oldenburg O.
Author information
Abstract
Sleep-disordered breathing (SDB) has a prognostic impact in patients with cardiac diseases. We included 257 patients with preserved left ventricular function and angiographically proven coronary artery disease (CAD). All patients underwent cardiorespiratory polygraphy. In 251 patients high-sensitive C-reactive protein and fibrinogen were measured. SDB was documented in 188 patients (apnea-hypopnea-index [AHI] 16.4+/- 1.9/h): 58 patients presented central sleep apnea (CSA) and 130 patients obstructive sleep apnea (OSA). All patients (73%) with SDB had higher blood fibrinogen levels than those without SDB (p = 0.01). We found 197 patients with CRP-values below the cut-off of 0.5 mg/dl (group 1) and 54 patients with no active infection but CRP>0.5 mg/dl (group 2). Severity of SDB was significantly higher in group 2 (p = 0.01). SDB has a high prevalence in CAD patients and seems to be associated with chronic inflammation, which may be linked to CAD progression and/or acute coronary events.

PMID: 20694765 DOI: 10.1007/s10354-009-0737-x
[Indexed for MEDLINE]

 

Here is another study that links hypertension and CAD.

 

Hypertension and coronary artery disease: cause and effect.
McInnes GT1.
Author information
1
University Department of Medicine and Therapeutics, Gardiner Institute, Western Infirmary, Glasgow, UK.
Abstract
NATURE OF RELATIONSHIP BETWEEN HYPERTENSION AND CORONARY ARTERY DISEASE: Epidemiological data indicate a strong and consistent link between hypertension and coronary artery disease. This does not mean that hypertension is the cause of coronary artery disease. Less than a quarter of the risk of developing coronary artery disease can be attributed to raised blood pressure. Furthermore, in individuals, hypertension is only weakly predictive and hence blood pressure cannot be relied upon to identify those with a particularly high risk. EFFECT OF A REDUCTION IN BLOOD PRESSURE ON CORONARY ARTERY DISEASE: The results of outcome trials, largely in men with mild to moderate uncomplicated hypertension, demonstrate that a modest short-term reduction in blood pressure confers a reduction in coronary artery disease events of about 16%, against the expectation from observational studies of about 22.5%. Explanations for the apparent shortfall include the putative theory that metabolic effects of the drugs used in the trials (mainly thiazides and beta-blockers) offset the beneficial effect of the blood pressure reduction. However, from consideration of epidemiological findings, it is clear that a large proportion (over 75%) of events in hypertensive patients is unlikely to be preventable by managing the elevated blood pressure alone.

TREATMENT CONSIDERATIONS:
Since arterial pressure interacts in a more than additive manner with coincident coronary risk factors, treatment should be initiated on the basis of overall risk and directed by predictors of myocardial infarction. In addition to a sustained level of blood pressure, these predictors include established coronary artery disease, older age and cigarette smoking.

BEYOND BLOOD PRESSURE REDUCTION:
Whether metabolically neutral antihypertensive drugs can reduce the shortfall between expected and observed benefit remains uncertain. However, some newer agents (angiotensin converting enzyme inhibitors and calcium antagonists) appear to have an effect on vascular structure and function that is independent of blood pressure reduction. If these advantages are confirmed in clinical trials, these drugs offer the prospect of a much greater impact on coronary artery disease than currently obtained.

This study suggests that hypertension does not cause CAD, but moreso, CAD causes hypertension. Claim it "Hypertension as Secondary to CAD."

Depending on the history of your blood pressure here is how hypertension is rated.

 

Your rating depends on your blood pressure reading. Per § 4.104-10 Code 7101:

If your diastolic pressure (bottom number) is 130 or higher: 60 percent rating
If your diastolic pressure is 120 to 129: 40 percent rating
If your diastolic pressure is 110 to 119, or your systolic pressure (top number) is 200 or higher: 20 percent rating
If your diastolic pressure is 100 to 109, or your systolic pressure is 160 to 199: 10 percent rating

If you get the highest ratings granted for Sleep Apnea and Hypertension here is the VA MATH: 10%+50%60%=82% rounded down to 80%. 

Requirements for Secondary Service Connection:

1. Current Service-Connected Disability

2. Current diagnosis/disability

3. Nexus of opinion linking #1 and #2. You only need a doctor to say #2 is being caused or aggravated "at least as likely as not" (equal to or greater than 50%probability) due to #1; and provide medical rationale to substantiate your claim.

I wish you well.

[broncovet]

Great post, FMFDoc25.  Are you in Harlingen TEXAS?  My son used to live in Harlingen (his wife was a PT).  They have moved to Dallas, however.  

You gave a great answer, and I dont have much to add, except that my opinion does not matter, nor does the opinion of the researcher.  The Veteran needs a nexus statement from his or her doctor about the veterans condition, not those in the research study.  

The success of the claim, as always, will hinge on whether or not the Veteran has the required Caluza elements, just as you have posted.

 

[ASU_0331]

On 4/6/2017 at 12:20 PM, VAW-126 said:

Can anyone tell me if Obstructive Sleep Apnea and Hypertension be secondary to CAD. Also the C&P examiner copied and pasted into my Heart Condition DBQ the following statements from my last cardiology exam. .

CC: 1st visit today. Pt w/ h/o chronic, stable angina - reported CP in service in 9/1990 - had NL MPI.  Has undergone heart CATHs (1993, 2008), which were NL except as noted below - advised he likely his microvascular disease, or microspasm, or (cardiac) syndrome X (decreased blood flow in LAD). Info in scanned records.

Pt has noted intermittent CP >25 years - avg 3x per month - occurs at rest or during sleep or w/ activity - pausing/resting typically relieves - uses one SL Nitro tab on avg of 1x per month to relieve CP.

The C&P examiner used the above cardiology exam as a Interview-based METs test because the limitation in METs level is due to multiple medical conditions including the heart condition, it is not possible to accurately estimate the percent of METs limitation attributable to each medical condition.

Based on the above statements from the Cardiologist could my SC heart condition be increased from 10% to 100%.

i. was also hospitalized in Dec 2016 for my heart condition in which a ECHO and Nuclear Stress Test was performed. My stress test showed I have a EF of 60%. But my ECHO revealed that I have the following:

Left Ventricular Basal Septal Hypertrophy, Left Ventricular Diastolic function abnormality with Mild (grade 1) showing impaired relaxation and Trace Mitral and Valve Regurgitation.

I also have a history of a past Myocardial Infarction when I was on active duty.

Did they do an echo cardiogram to determine your current ejection fraction rate?  Right now you are at 60% ejection fraction which means all you rate is the 10% despite the other issues the C&P included.  Did he give an estimated METS range that you have not included here?  These are the criteria for heart ratings;

With history of documented myocardial infarction, 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