VA Disability Ratings for Heart and Cardiovascular Conditions
READ the blog post here: https://cck-law.com/types-of-va-disabilities/heart-conditions/
Jenna Zellmer: Good afternoon and welcome to CCK Live and Happy Halloween. My name is Jenna Zellmer and joining me today are Emma Peterson and Courtney Ross and today, we’re going to be talking about heart conditions and other related cardiovascular conditions. As always, if you have any questions, please feel free to leave them in the comment box below. We’ll do our best to answer them. And we’ll also be posting links to additional information that can be found on our website at cck-law.com. So, let’s get right into it. Nearly one million veterans have service-related cardiovascular conditions. So, this is a very timely and relevant topic. I would say that they’re most commonly rated at 10%. And so, even though they are not always the most compensable rated disabilities, that doesn’t necessarily mean that they’re not important. So, Emma, can you talk to us a little bit about what the most common cardiovascular conditions veterans can have and get service-connected for?
Emma Peterson: Sure. So one of the big ones that we talk about a lot, not just in the context of diseases in general, but Agent Orange presumptions is coronary artery disease, also known as ischemic heart disease. So, a lot of veterans who were exposed to herbicides ended up developing this disease and can get that presumptively service connection. But a lot of veterans just end up developing CAD later in life either, again, due to service or due to other conditions that are service-connected. And the other very common one that we see a lot of is hypertension. So, both of those are probably the two most common heart conditions that we see with our clients.
Jenna Zellmer: Great. And first, we are going to talk a little bit about different ways to get service-connected for these cardiovascular conditions. And then we’ll go into the ratings but we have a lot of information on our website, and I’m sure we’ve done several Facebook Lives in the past about a second– about direct service connection, but Courtney, do you just want to give us a quick refresher on how a veteran can get direct service connection for a heart condition?
Courtney Ross: Yes, absolutely. So, you’ll need a diagnosed heart condition. And then you will need an in-service event or illness. So, it could be what Emma suggested– exposure to herbicides in service or it could be that you actually had an onset of symptoms of your heart condition in service. And then you’ll need a medical Nexus. So, likely a medical opinion linking your currently diagnosed heart condition to that event or illness in service.
Jenna Zellmer: Great. And I think that this is a good time to kind of delve in a little bit more into that Agent Orange presumption that you both discussed. So, we have a direct service connection where you can use that three-step process and get a Nexus, but under the Agent Orange presumption, there is an easier way to get service connection, at least for CAD right now. Is that right, Emma?
Emma Peterson: Yes. So, for CAD-ischemic heart disease, if you can show that you are exposed to an herbicide whether be it in Vietnam, Thailand or now for our blue water veterans, with a new legislation if you can show that you are exposed to an herbicide and you have a current diagnosis, you do not need that Nexus evidence, it is going to be presumptively service-connected. So, that eliminates part of the burden in terms of getting service connection.
Jenna Zellmer: And I think the VA has different time periods during which it is already established that Agent Orange was used in those different areas. So, the DMZ, Vietnam and blue water, etc. And so, to the extent that you mentioned, if you can show a lot of times just by serving in those areas, that has been enough to demonstrate that you were exposed to Agent Orange. And so, I would really recommend checking out our website. There’s a lot of information about the new Blue Water legislation that you just mentioned, which is that essentially extends that presumption to veterans who were serving in the Navy, who potentially did not set foot on the ground in Vietnam, but were still exposed to Agent Orange. And so, that just lets– lessens the burden for veterans to demonstrate because I think it would be pretty hard to show that you are exposed to Agent Orange.
Courtney Ross: Yes, absolutely.
Jenna Zellmer: And so, you mentioned that that is just for CAD or for ischemic heart disease. What about hypertension?
Emma Peterson: So, hypertension historically has not been– well historical, it is not currently one of the presumptive conditions for service connection. However, in 2018, the National Academy of Sciences, which does these annual or bi-annual reviews of the evidence linking certain conditions to herbicide exposure finally indicated that there was sufficient evidence linking the development of hypertension with Agent Orange exposure. There was a lot of rumblings and a lot of communication coming out of VA indicating that hypertension was going to be added as a presumptive condition. And then that just stalled out talks about that are really– we do not really know too much more about when that is going to be added as a presumptive condition.
Jenna Zellmer: Hopefully, ongoing sometime in the future.
Emma Peterson: You know, we certainly hear it next couple of months, next couple of months. And it has sort of come up in the news again lately. So, feel free to Google that if you are interested in to see what is going on lately with the hypertension presumption. But unfortunately, it is not a presumptive condition now just because it is not presumptive it does not mean you cannot get it service-connected with some medical Nexus evidence. And certainly, that opinion report from the National Academy of Sciences is very persuasive. So submitting that, getting together with your representative, your VSO, whoever you work with on your claim, to either submit that report or submitting it to your doctor to look at and then providing a nexus opinion, certainly could be a path to getting you service-connected for hypertension.
Jenna Zellmer: Yes, and I think it’s really important. For example, this National Academy’s report, even though it is fairly well known, the board is not going to necessarily need to discuss it, unless you and your representative submit it and make an argument about why it should be considered in support of your claim. There has been some case law recently about what the board should be, should know about despite it potentially not being in the record, and so it’s always good to be on the safe side. And if you think that there are some medical literature out there that would support your claim, just talk to your VSO or your attorney about potentially submitting that as part of your claim and making potentially an argument about why it should help you in support of your claim. And so, that is something to note. And so, studies like the NAS report are really helpful. And so, we– you can find information on our website about that as well. So, Courtney, we talked about direct service connection, we’ve talked about presumptive service connection. But is there another way that veterans could potentially get service-connected for heart conditions that maybe are not directly related to service or are not related to an Agent Orange exposure?
Courtney Ross: Yes. So, veterans may be service-connected secondary to a condition that they are already service-connected for. And I will give you some examples to kind of provide some context to that. So, there is medical literature that supports if a veteran is maybe already service-connected for a condition like diabetes. It is possible that diabetes could cause a heart condition or aggravate maybe a heart condition that the veteran already has. And if you are able to show that through medical evidence, a veteran can also be service-connected for a heart condition that way. Another common example is PTSD or other types of anxiety-inducing psychiatric conditions. Literature also supports that there is a connection between those psychiatric conditions and how they might impact or cars– or cause rather, heart conditions. Certain types of medications that you might be taking to treat service-connected conditions could also have possible impacts on your heart condition. So, these are all different things that you want to consider if you have a heart condition and you are trying to find a way to link it to– or you think it is due to your time and service. It may not be directly due to your time and service, but it may be related to a condition that you have as a result of your time in service.
Jenna Zellmer: And we have done Facebook Lives and we have a lot of information on our website about secondary service connection and what you need to demonstrate in order to meet that standard. So, that is a little bit different than direct service connection. But the good thing to know is that you do not necessarily need a heart condition in service you can potentially get a heart condition after service related to some other service-connected disability. And so, it is important to kind of talk to your rep and potentially your doctor and kind of explore all different avenues of service connection just because you cannot prove one does not necessarily mean you cannot get service-connected. So, those are kind of the different ways that veterans with cardiovascular conditions can demonstrate service connection. So, let us go on and let us just assume that VA has already acknowledged that a veteran has a service-connected heart condition. Let us talk about the kind of ratings. So, Emma, do you want to talk about METs or metabolic equivalent tests?
Emma Peterson: Sure. So, the way that the cardio– heart conditions, like I mentioned before, CAD, are rated– is based on a series of tests that a VA examiner most likely will perform. Your private doctor will perform them too, but really they test just sort of the efficiency and function of your heart. So, one big one that is included in most of the diagnostic criteria for heart conditions are the METs testing, the metabolic equivalence test, otherwise known as exercise testing. So, it measures the energy cost on your heart for doing different physical activities. And it also measures when and sort of how strenuous at an activity you are doing. You start to feel symptoms. So, if you are walking and you already are out of breath and feeling – I cannot say this word to save my life– dyspnea, dyspnea?
Jenna Zellmer: Yes.
Emma Peterson: Dyspnea?
Jenna Zellmer: Yes, essentially shortness of breath.
Courtney Ross: Yes.
Emma Peterson: It is just the word
Jenna Zellmer: Yes, yes.
Emma Peterson: Too many consonants.
Jenna Zellmer: Well, I think this is really helpful too because a lot of times veterans are looking at these rating criteria, and they do not even know what these things say.
Emma Peterson: Right.
Jenna Zellmer: And so, you know? With the use of–
Emma Peterson: Shortness of breath.
Courtney Ross: Yes.
Emma Peterson: Say you are walking, you are feeling shortness of breath, obviously, that is going to result in a low METs rating. Because at that low level, you are already feeling the symptoms. So, what they do is the higher the METs rating the more efficient the more functioning your heart is, and the lower your disability rating is going to be. Look at shortness of breath, fatigue, angina – which is heart pain-, dizziness, fainting, loss of consciousness. And then also they consider the medications that you might have to take to maintain your condition.
Jenna Zellmer: I think it is really important to kind of, in cases like this, where the rating criteria is pretty objective, it requires an examiner to either interview you or do an exercise-based test and then make a determination based on those tests what level you are at. It is really important to talk to your doctor and talk to your rep, provide evidence about kind of the daily activities that you struggle with due to your cardiovascular disease. And so, Courtney, do you want to kind of talk about– you know, I mentioned earlier, a lot of veterans are only rated at 10%, but there is obviously a broad spectrum. What are kind of the symptoms that are– the VA considers totally disabling? Like, what are the things that it is going to look for when veterans are submitting an increased rating claim?
Courtney Ross: Yes. So similar to what Emma was alluding to, if you are on doing physical activity that is just something like showering or walking one block, or just while you are getting dressed, you are starting to suffer from some of those symptoms. So, the shortness of breath, the chest pain, the fatigue, those are the kind of things that the veteran– excuse me, the VA is going to look for to say that your heart condition is totally disabling. Chronic congestive heart failure is another thing that VA will consider in terms of granting you a total disability rating for your heart condition.
Jenna Zellmer: Yes. So, anywhere between that spectrum. So, if you can walk, let us say a mile or two but you still feel shortness of breath, maybe that is a 10% rating. But if you really cannot do anything, without you needing to stop a lot, you need help, maybe dressing or eating or anything like that. That is something that the VA is going to consider. And so, it is really important to tell VA what issues you are having and be really upfront. Do not try to minimize any of the experiences that you have because you want to make sure that you are getting the compensation.
Emma Peterson: I think that is really important because sometimes, due to the severity of your heart condition, doing an actual METs testing, an actual exercise test is not going to be indicated. So, they will do interview-based METs testing and in that interview, they will ask you what happens after you walk a block? What happens after you do X, Y, and Z? so it is very important that you are very clear about when you start feeling these symptoms because they are just going to be estimating they’re not actually going to make you do the physical exercise. Because again, it might be that you are at the 80% range, and they are looking at a 100% and it is just not safe to make you start running on a treadmill.
Jenna Zellmer: Right.
Emma Peterson: So again, if you are in that situation, make sure that you are explaining how this impacts you in your day to day life.
Jenna Zellmer: Mhmm. So, that is for cardiovascular conditions– heart conditions. But in the beginning, we talked about how there is CAD or ischemic heart disease. They are named the same, they are used interchangeably, which is sometimes a little bit confusing. But then we also have hypertension. And hypertension is not rated based on METs levels. So Courtney, do you want to talk a little bit about how VA rates hypertension?
Courtney Ross: Sure. It is rated based on your systolic and diastolic readings or pressure. So we have– most of us have been to the doctor where they put the little blood pressure cuff on your arm and they listen as they blow it up on your arm and they listen for the two different ticks. And those two different ticks are indicating where your systolic and diastolic pressure is and usually they will give you one number over the other. The diastolic pressure is the bottom number and the systolic is the top number. So, VA uses, again, it is very objective, uses those readings to determine what your rating should be for hypertension.
Jenna Zellmer: Yes. And I think despite the fact that both METs testing and hypertension read– high blood pressure readings are both objective. I think there is– that is really hard to kind of use lay statements to demonstrate that you meet a higher rating. It is really just based on what that blood pressure reading says. And so unfortunately, there is just– that is just a higher standard.
Courtney Ross: Yes. I think one thing to keep in mind with hypertension, though is usually if your hypertension is so severe that it warrants you a higher rating for– based on VA’s rating criteria for hypertension. Typically, you also have other medical conditions that have developed from that, including heart conditions, which can also develop secondary to hypertension. So, while you might not be able to be rated as highly just for hypertension, consider what other conditions you have as a result of your hypertension because you may be able to get secondary service-connected– service connection and a higher combined rating overall.
Jenna Zellmer: I think that is a really good point and it is VAs duty to kind of make those leaps. The connections between a disability and a potential other ratings. It is VA’s duty to maximize the veterans’ ratings, but it is always helpful to help VA do their job, make it as easy as possible for them to grant you the highest possible rating. And so, if you can talk to your rep about that, and kind of look at the regs and look and see what other potential compensation you might be entitled to. It is super easy if you just kind of like give it all to VA and just let them stamp it rather than relying on them to correctly apply the law.
Emma Peterson: I think one pitfall, just backing up to service connection to with hypertension that we see, is that the rating criteria require that the readings be taken over a series of days. It is not just you had a one-time high blood pressure reading, therefore you have hypertension. So, a lot of times we will see folks that have a singular high blood pressure reading in service. And then subsequent readings are maybe normal but they end up getting diagnosed with hypertension outside of service. But that does not count as a diagnosis for VA purposes. But again, that is not to say that you cannot still get service-connected by getting some medical evidence, your doctor, or your PCP to opine that first reading was the start of your hypertension. But that is just something to be aware of that just because you have that one high blood pressure readings. A lot of times we will see VA explain it away, oh, they were sick. They are on cold medication. They are stressed out. Subsequent readings were lower. They do require that it is over several days. So, just something to keep in mind. It is not a barrier, but it might be something that you face. So, just be aware of that.
Jenna Zellmer: And I think– yes, it’s really helpful to look and see what VA actually considers hypertension is because high blood pressure is kind of a range, certain people are pre-hypertensive versus actually having hypertension. And so, it is important to keep a–you can measure your blood pressure health, you can go– I am sure like CVS still has those. And keep a journal of what your blood pressure readings are and so that you can make sure that VA is getting a full picture of your actual disability. And you are not getting shortchanged just because you only go to a doctor one day. Great. This is really helpful. Just as a reminder, if anyone has any questions, please feel free to leave them in the comments box below. We love to answer your questions. And we know that this is a really complicated area of law. The heart, I think, is different than having a knee problem like because it’s internal. And so it leaves a little bit of mystery. So great. Let us move on. So, we have talked about kind of how VA rates of heart conditions and hypertension now, but VA is actually– has proposed some changes to how they rate heart diseases. And so, Courtney, do you want to kind of give a little overview about what VA is going to do in the future?
Courtney Ross: Yes. So, the proposed changes are really to make it so that the METs testing is going to be the primary way that they rate heart conditions. So, we have alluded to this throughout the broadcast, but other things they look at in our part of the criteria are things like measurement of ejection fraction of the left ventricle, and then episodes of congestive heart failure. So, the proposed changes are proposing to do away with those things, so to take them out of the criteria and really focus on the METs testing. They are also proposing to clarify that.
Jenna Zellmer: Dyspnea
Emma Peterson: Yes
Courtney Ross: Yes, I also struggled with some of that.
Emma Peterson: Someone could write in the comments how you pronounce that. That would be–
Jenna Zellmer: Dyspnea–
Courtney Ross: is really referring to breathlessness or shortness of breath.
Jenna Zellmer: Yes. I think that makes sense. Because then you won’t require people to–
Emma Peterson: Say Dyspnea.
Courtney Ross: Yes.
Jenna Zellmer: Or look it up, because that is not really a common phrase for something that is as common as shortness of breath. So, it makes it a little bit clear.
Courtney Ross: Yes.
Jenna Zellmer: So, we talked a little bit about, how a veteran could potentially get 100% rating under the rating criteria. There are a couple of other ways the veterans can get 100% ratings. So, let us talk a little bit about temporary total ratings.
Emma Peterson: Sure. So if you have, for example, the big one is a heart attack. You will be rated at 100% for three months following that incident. And then you will be reevaluated based on your METs testing and seeing how severe the resulting condition is. But for those three months after the heart attack, you will get a 100% rating. Some other ways that you can get a temporary total rating. So, temporary hundred percent is if you have had a pacemaker installed. They will give that to you for two months following the surgery. And then will re-rate you and see how severe the condition is. There is something else out there now these days called an ICD or ACID, which is an implantable cardiac defibrillator. It is like a pacemaker in the same way it works the same way and that it senses when your heart is out of rhythm, it is beating too fast or regularly and– but it gives you a shock. Kind of like the full-on defibrillator machines that you might see in your favorite medical drama, but it is implanted actually right into your heart. If you have one of those, that is 100% rating.
Jenna Zellmer: The entire time?
Emma Peterson: The entire time. So, it is important to find out whether you are getting a pacemaker or an ICD because that makes a drastic difference in your rating. If you have a heart valve replacement while being treated, and then six months following that treatment – that replacement – do that and get reevaluated. And then finally a heart transplant will get 100% for one year.
Jenna Zellmer: Yes.
Emma Peterson: And then re-evaluated based on your new heart. So, hopefully at that point, things are much better.
Jenna Zellmer: Yes, probably. If things are going well, you will not get a good– higher rating.
Emma Peterson: good rating, but you will have a healthy heart. That is the most important thing.
Jenna Zellmer: Exactly.
Jenna Zellmer: And then finally, as always, we would have to touch a little bit on TDIU. So Courtney, do you want to give us a brief refresher on TDIU? Actually, do we have a question? Before we get into TDIU, let us answer this question. So Jose says, “Would being overweight due to back problems and other issues affect the heart resulting in a condition that we can apply for compensation?” That is a really excellent question. And I think that it kind of relates back to secondary service connection. So Courtney, do you want to touch on that?
Courtney Ross: Yes, absolutely. So yes, but it will be seen and serve as an intermediate step for that secondary service connection. So, if you have a back condition that is already service-connected, and so disabling that it causes you to become obese. And that obesity then results in your heart condition. It is that middle step there that then makes the obesity is the middle stuff there that connects your back– service-connected back condition and the resulting heart condition. So, you can use that to link the two and then get service connection for the heart.
Jenna Zellmer: Yes.
Emma Peterson: Also another way– I mean, this is not exactly the question, but we talked about medications. So, if you are taking medications for the back pain that increase your blood pressure, or long-term medications, long term steroids treatment could affect it. And then also, if you had an example and–
Jenna Zellmer: Well if your medication causes weight gain.
Emma Peterson: Right. That is what it was. Yes, taking medication that causes weight gain. That also could be the intermediate step. But yes, obesity can be the link between the two.
Jenna Zellmer: Yes. So, a few years ago, VA and the court had made clear that you cannot get a disability rating based on obesity. But VAs general counsel has come out and said, they recognize obesity can be the step between a service connected disability and another disability. And so, it is a little unclear kind of how that relates. Like what the standard is between the service connected condition and obesity. And then what the standard is between the obesity and the secondary condition. And so, I think it is really helpful if you are going to be making those types of arguments to consult your rep, either a VSO or an attorney, and really make sure that they are doing research on what VA is going to require to demonstrate that link. Because it is so– there is so many links in the chain. Yeah. And so, that’s a really great question.
Courtney Ross: Yes.
Jenna Zellmer: Great. So let us go back to TDIU. And I just talked to Courtney. So, I will go back to Emma. And Emma can talk a little bit about TDIU.
Emma Peterson: Sure. So yes, you asked. You, of course, can get TDIU based on a heart condition. And certainly, heart conditions would impact your ability to do all kinds of work. And if you are getting out of breath, just showering and getting dressed, you certainly are not going to be able to do any type of physical or strenuous labor. Probably not even a desk job necessarily getting to and from work might just be impossible. But you absolutely can apply for TDIU as part of an increased rating for your service-connected heart condition, also and then in conjunction with other conditions that you have. So, as always TDIU is on the table if a service connected a disability is preventing you from being able to secure and follow a substantially gainful job.
Jenna Zellmer: And we have a lot of information on TDIU, and what VA considers when it is determining whether or not a veteran can obtain and maintain a job. Do you have any final closing thoughts on TDIU?
Courtney Ross: I think just– oh, on TDIU?
Jenna Zellmer: Or closing thoughts.
Courtney Ross: I am just going to say closing thoughts on the heart conditions in general. I think as you have heard throughout the broadcast, there is many different ways that you can get possibly compensated for your heart condition. So, you just want to make sure that if you are suffering from heart condition that you really taking into consideration all of the different possible avenues. Like you have said a few times, to talk to your rep, or talk to your doctor to see if they can provide medical evidence and support of your case, because it is not really a one size fits all for each case.
Jenna Zellmer: Yes. And I think, going back to that, talking to your doctor– there are certain disabilities that you can get service-connected for. That are really, you are competent as a layperson to describe and to say that you have a certain condition but for the heart like I said earlier, it is a little bit more complicated and so getting good evidence from your doctor to support your claim for service connection or your claim for an increased rating. I would really suggest you doing that. Do you have any questions– closing thoughts?
Emma Peterson: Questions? I have lots of questions. No, I think that that is a fair point. And like you mentioned the hearts internal is not like any, where you can you know, see how far your knees are bending.
Jenna Zellmer: Right You cannot see like a swelling– a swollen knee.
Emma Peterson: Right, right, you can’t see like your ejection fraction and see your METs testing. So, while all your lay evidence about your symptoms, your breathlessness you know how it impacts your life is very valuable. At the end of the day, these are a lot of objective medical tests. They are going to perform and it might really box in your rating. So, you know, do not be disheartened, no pun intended [laughter]. But just know that this criteria is out there. So, talking with your doctor is very important.
Jenna Zellmer: Great. Well, thanks for joining us. And again, Happy Halloween. I hope everyone stays safe. And we will see you next week.
