Citation Nr: 0627480 Decision Date: 08/30/06 Archive Date: 09/06/06 DOCKET NO. 00-20 856A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUE Entitlement to service connection for a cardiovascular disability. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD John Francis, Associate Counsel INTRODUCTION The veteran served on active duty from June 1970 to December 1971. This appeal comes before the Board of Veterans' Appeals (Board) from a December 1998 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) that denied a petition to reopen a final disallowed claim for service connection for hypertensive cardiovascular disease with myocardial ischemia. In a February 2002 statement of the case, the RO reopened the claim and denied it on the merits. On appeal in September 2002, the Board reopened the claim and in August 2003 remanded it to the RO for further development. FINDING OF FACT The veteran's hypertension with left ventricular hypertrophy manifested many years after service and is not related to any incident of service. CONCLUSION OF LAW The criteria for service connection for hypertensive heart disease have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2005). REASONS AND BASES FOR FINDING AND CONCLUSION Upon receipt of a complete or substantially complete application, VA must notify the claimant and any representative of any information, medical evidence, or lay evidence not previously provided to VA that is necessary to substantiate the claim. This notice requires VA to indicate which portion of that information and evidence is to be provided by the claimant and which portion VA will attempt to obtain on the claimant's behalf. See 38 U.S.C.A. §§ 5103, 5103A, 5107 (West 2002 & Supp. 2005); 38 C.F.R. § 3.159 (2005). The notice must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; (3) inform the claimant about the information and evidence the claimant is expected to provide; and (4) request or tell the claimant to provide any evidence in the claimant's possession that pertains to the claim, or something to the effect that the claimant should "give us everything you've got pertaining to your claim(s)." Pelegrini v. Principi, 18 Vet. App. 112 (2004). Here, the RO sent correspondence in January 2003, November 2004, and March 2006; a rating decision in January 1999; and statements of the case in August 2000 and February 2002. These documents discussed specific evidence, the particular legal requirements applicable to the claim, the evidence considered, the pertinent laws and regulations, and the reasons for the decisions. VA made all efforts to notify and to assist the appellant with regard to the evidence obtained, the evidence needed, the responsibilities of the parties in obtaining the evidence, and the general notice of the need for any evidence in the appellant's possession. The Board finds that any defect with regard to the timing or content of the notice to the appellant is harmless because of the thorough and informative notices provided throughout the adjudication and because the appellant had a meaningful opportunity to participate effectively in the processing of the claim with an adjudication of the claim by the RO subsequent to receipt of the required notice. There has been no prejudice to the appellant, and any defect in the timing or content of the notices has not affected the fairness of the adjudication. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006) (specifically declining to address harmless error doctrine); see also Dingess v. Nicholson, 19 Vet. App. 473 (2006). Thus, VA has satisfied its duty to notify the appellant and had satisfied that duty prior to the final adjudication in the April 2006 supplemental statement of the case. In addition, all relevant, identified, and available evidence has been obtained, and VA has notified the veteran of any evidence that could not be obtained. The appellant has not referred to any additional, unobtained, relevant evidence. VA has obtained an examination. Thus, the Board finds that VA has satisfied both the notice and duty to assist provisions of the law. The veteran contends that he has hypertension and cardiovascular disease with myocardial ischemia that first manifested in service. He also contends that he sought treatment from VA within one year of discharge and that records of that treatment are available but were not obtained by VA. Service connection may be granted for disability resulting from a disease or injury incurred in or aggravated by military service. For the showing of chronic disease in service, there must be a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. If chronicity in service is not established, evidence of continuity of symptoms after discharge is required to support the claim. Service connection may also be granted for a disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. Chronic diseases, including cardiovascular disease, may also be presumed to be service connected if the disease became manifest to a degree of 10 percent or more within one year of discharge. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303, 3.307. In order to establish direct service connection for a claimed disorder, there must be (1) medical evidence of current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in- service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997); Brammer v. Derwinski, 3 Vet. App. 223 (1992). Such determination is based on an analysis of all the evidence of record and evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1, 8 (1999). The veteran's induction physical examination in June 1970 showed no heart or vascular abnormalities and normal blood pressure. In June 1970, the veteran sought treatment for shortness of breath while running that was diagnosed as a substernal bruise. Three days later he presented again with chest pains and shortness of breath. The examiner diagnosed an upper respiratory infection and prescribed cough medicine and aspirin. In November 1970, the veteran again sought treatment for cough and chest pain. An X-ray was normal and the diagnosis was bronchitis. He also was treated for upper respiratory infections in April 1971 and November 1971. In each case there was no immediate follow-up after the initial treatment and no restriction of duty or physical activities. In September 1971, the veteran's discharge physical examination showed no heart or vascular abnormalities. Blood pressure was 120/66 mm Hg. The veteran reported a history of pain or pressure in chest; however, the examiner noted that the episodes had resolved. In a December 1996 appeal and in an October 2001 RO hearing, the veteran stated that he sought treatment within one year of discharge at the VA Medical Center (VAMC) at Fort Hamilton, Brooklyn, New York. However, in his January 1981 claim, he indicated that his first treatment for a heart condition at that VAMC and at a private hospital was in 1975. He stated that he received an electrocardiogram, a CAT scan, and a "balloon treatment," and was diagnosed with angina. He further stated that he had made three trips to the VAMC in search of his records and that he was able to retrieve only a small portion of the total number that he believed were generated during his treatment. Despite two requests, the RO was unable to obtain any additional records from the VAMC or the private hospital. VAMC Brooklyn records submitted by the veteran showed that he was treated in June 1972 for trauma to his right eye and in August 1972 for venereal ulcers. On the latter occasion, his blood pressure was 140/90 mm Hg and it was noted that there were no known allergies, heart condition, or diabetes. In November 1974, after an automobile accident and initial treatment at a private hospital, the veteran sought follow-up orthopedic care for a cervical strain. His blood pressure was 142/90 mm Hg. There is no record of examination, testing, or diagnosis of hypertension or cardiovascular disease at VAMC Brooklyn. In December 1980, a VA medical certificate showed that the veteran was issued a refill prescription for isosorbide dinitrate, a medication used in the treatment of angina. Dorland's Illustrated Medical Dictionary 865 (28th ed. 1994). The veteran filed a claim for compensation for a heart condition in January 1981. In February 1981, a VA examiner noted that the veteran stated that he had been told that he had high blood pressure and an enlarged heart. The veteran stated that he took nitroglycerine for chest pains on exertion. The examiner recorded blood pressure as 128/90 mm Hg and noted that the veteran was not taking a high blood pressure control medication. On examination, he noted slight evidence of enlargement of the left side of the heart and diagnosed hypertensive cardiovascular disease with myocardial ischemia. A March 1981 electrocardiogram showed left ventricular hypertrophy. In October 1981, the veteran was examined for enlistment in the Army National Guard. On his medical history questionnaire, the veteran reported no shortness of breath or chest pain. He stated that he was in good health, taking no medications. The examiner noted no abnormal heart or vascular conditions. Blood pressure was 142/86 mm Hg. He was found qualified for worldwide military duty. In March 1982, a VA examiner measured blood pressure as 156/106 mm Hg. On examination, he noted that the heart was normal and that an electrocardiogram elevated voltage was likely normal for a young person. He concluded that angina was doubtful, but admitted the veteran to the hospital for a stress test and cardiologist evaluation. He prescribed diuretic medication for blood pressure. The April 1982 stress test could not be completed because the veteran complained of chest pain and "did not appear to be well motivated." However, a subsequent thallium scan was normal with no indications of myocardial ischemia or infarction. A chest X-ray was unremarkable and an electrocardiogram showed only left ventricular hypertrophy. The cardiologist noted that the veteran's pain seemed to be caused by worry and might be more functional than organic. At the end of April 1982, another VA examiner noted the veteran's reported heart trouble for the past two years. The veteran was now taking blood pressure medication and was experiencing shortness of breath after walking several blocks. The examiner noted no evidence of heart enlargement. Blood pressure was 130/80 mm Hg. In October 1982, the veteran noted in an Army reserve medical history questionnaire that he had no significant illness since his last examination and was taking no medication. In April 1986, the veteran was hospitalized at a private facility for two episodes of syncope. The examiner noted that the veteran had not been complying with his blood pressure medication and was experiencing employment and domestic stress. He diagnosed episodic hypertension, anxiety, and syncope with etiology undetermined. VA records from 1986 to 1996 show occasional complaints of chest pain of undetermined etiology and refills of hypertension medication. In September 1996, a VA examiner diagnosed hypertension with angina. In April 1998, a Social Security Administration (SSA) consultant cardiologist noted high blood pressure but no heart disease. In June 1998, another SSA medical consultant referred to a recent X-ray and upon examination concluded that the veteran did not have congestive heart failure and that the veteran's pain was not credible as alleged. In a September 1998 VA medical status statement, a physician's assistant stated that the veteran was in good health with hypertension under control. In September 2001, a VA myocardial perfusion scan showed normal perfusion with mild diffuse impairment of left ventricular wall motion and no ischemia. Finally, in June 2005, a VA examiner reviewed the entire file and the results of a March 2001 inconclusive exercise tolerance test and the September 2001 perfusion scan. In addition, he reviewed the results of a concurrent chest X- ray, electrocardiogram, and echocardiogram. He diagnosed hypertension, controlled by medication, with evidence of left ventricular hypertrophy but normal wall motion and global systolic function. He stated that the veteran's hypertension was not likely related to service since the record showed no diagnosis until the 1980's. He concluded that the high blood pressure readings in 1974 were likely due to concurrent headache and neck pain. The medical evidence shows that the veteran has high blood pressure, controlled by medication. The medical evidence does not show that the veteran has hypertensive cardiovascular disease, or any other diagnosed heart disease. Episodes of high blood pressure occurred most often after medical providers noted a lack of medication compliance. On one occasion in February 1981, one examiner diagnosed hypertensive cardiovascular disease. However, he did not refer to any diagnostic testing. Notably, the diagnosis was not continued after additional testing in 1982, and no other examiner has diagnosed cardiovascular disease or found evidence of a myocardial infarction since that time. Several examiners referred to non-organic causes for the veteran's chest pain including stress from employment and domestic problems. The Board concludes that the veteran's hypertension first manifested no earlier than February 1981 when diagnosed by a VA physician. Service medical records showed that all complaints of chest pain in service were related to lung or upper respiratory infections and were promptly resolved. VAMC Brooklyn records from 1972 to 1974 showed one isolated elevated blood pressure measurement taken in conjunction with unrelated treatment. There is no evidence of examination, testing, or "balloon treatment" for hypertension or cardiovascular disease. Although the veteran sought a medication refill from VA in December 1980, referring to earlier medical providers whose clinical reports are not of record, he also stated in 1982 that he had been having "heart trouble" for only the previous two years. There is no evidence that the veteran's hypertension became manifest to a degree of 10 percent or more within one year of discharge. The Board has considered the veteran's contention that many records from VAMC Brooklyn were missing and that he was able to obtain some records despite the two negative responses to RO requests. Nevertheless, the records that were obtained cover several years immediately following service and show treatment for relatively minor, non-cardiovascular conditions. It is unlikely that records of examination for a cardiovascular condition would be filed in another location. The Board notes that the credibility of the veteran's history and descriptions of pain were questioned by several providers. In addition, the Board notes the inconsistency between the veteran's reports to VA providers and his reports to Army reserve examiners in 1981 and 1982. In sum, the evidence demonstrates that the veteran's current symptoms of hypertension were first manifested many years after service and are not related to his active service or any incident therein. As the preponderance of the evidence is against this claim, the "benefit of the doubt" rule is not for application, and the claim must be denied. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for a cardiovascular disability is denied. ____________________________________________ RONALD W. SCHOLZ Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs