Citation Nr: 0303281 Decision Date: 02/25/03 Archive Date: 03/05/03 DOCKET NO. 00-06 039 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUES 1. Entitlement to service connection for a functional heart murmur. 2. Entitlement to service connection for hypertension. 3. Entitlement to service connection for organic heart disease manifested by hyperlipidemia (elevated cholesterol). REPRESENTATION Appellant represented by: California Department of Veterans Affairs ATTORNEY FOR THE BOARD Clifford R. Olson, Counsel INTRODUCTION The veteran's active military service extended from May 1990 to September 1998. This matter comes before the Board of Veterans' Appeals (Board) from the Department of Veterans Affairs (VA) Regional Office (RO) in Los Angeles, California. The case was previously before the Board in March 2001, when it was remanded for further development. The requested development has been completed. The Board now proceeds with its review of the appeal. FINDINGS OF FACT 1. VA has made all reasonable efforts to assist the appellant in the development of his claim and has notified him of the information and evidence necessary to substantiate his claim. 2. The veteran does not have a heart murmur disability due to disease or injury. 3. The veteran does not have hypertension. 4. The veteran does not have organic heart disease manifested by hyperlipidemia (elevated cholesterol). CONCLUSIONS OF LAW 1. A heart murmur disability was not incurred in or aggravated by active military service and may not be presumed to have been incurred in service. 38 U.S.C.A. §§ 101(16), 1101, 1110, 1112, 1131, 1137 (West 1991); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2002). 2. Hypertension was not incurred in or aggravated by active military service and may not be presumed to have been incurred in service. 38 U.S.C.A. §§ 101(16), 1101, 1110, 1112, 1131, 1137 (West 1991); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2002). 3. Organic heart disease manifested by hyperlipidemia (elevated cholesterol) was not incurred in or aggravated by active military service and may not be presumed to have been incurred in service. 38 U.S.C.A. §§ 101(16), 1101, 1110, 1112, 1131, 1137 (West 1991); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2002). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (herein "VCAA") became law on November 9, 2000. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107 (West Supp. 2002). Further, implementing regulations have been published. 38 C.F.R §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2002). Except for amendments not applicable here, the provisions of the regulations merely implement the VCAA and do not provide any rights other than those provided by the VCAA. See 66 Fed. Reg. 45,629 (Aug. 29, 2001). The RO considered the case under VCAA, implementing regulations and VA guidance issued pursuant to that act and regulations. The RO provided the veteran with the pertinent evidentiary development, which was subsequently codified by VCAA and implementing regulations. In addition to performing the pertinent development required under VCAA, the RO notified the veteran of his right to submit evidence. Thus, the Board finds VA has completed its duties under VCAA and implementing regulations. Further, VA has completed the development of this case under all applicable law, regulations and VA procedural guidance. See also 38 C.F.R. § 3.103 (2002). Therefore, it would not abridge the appellant's rights under VCAA and implementing regulations for the Board to proceed to review the appeal. Specifically, the veteran's application is complete. The rating decision, statement of the case, and supplemental statements of the case, as well as letters dated in April 2001 and December 2002, notified the veteran and his representative of the evidence necessary to substantiate the claim, the evidence which had been received, and the evidence to be provided by the claimant. Cf. Quartuccio v. Principi, 16 Vet. App. 183, 187, 188 (2002). VA has made reasonable efforts to assist the veteran in obtaining evidence necessary to substantiate his claim for benefits. There is no reasonable possibility that further assistance would aid in substantiating the claim. VA has made reasonable efforts to obtain relevant records (including private records) which the veteran adequately identified and authorized VA to obtain. All relevant Federal records have been obtained. The service medical records are in the claims folder. VA records have been obtained. The veteran has been examined by VA and a medical opinion rendered. The veteran has not reported that any other pertinent evidence might be available. See Epps v. Brown, 9 Vet. App. 341, 344 (1996). Notably, neither the appellant nor the representative has asserted that the case requires further development or action under VCAA or its implementing regulations. Service connection is granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 101(16), 1110, 1131 (West 1991). Analysis of this provision discloses that there are three essential elements which must be met to establish entitlement. There must be current disability; there must be disease or injury during service, and there must be a nexus or connection relating the current disability to the disease or injury during service. Further, the evidence must be competent. That is, an injury during service may be verified by medical or lay witness statements; however, the presence of a current disability requires a medical diagnosis; and, where an opinion is used to link the current disorder to a cause during service, a competent opinion of a medical professional is required. See Caluza v. Brown, 7 Vet. App. 498 (1995); see also 38 C.F.R. § 3.159(a) (2002). Of particular significance in this case is the need for competent evidence from a medical professional which diagnoses a current disability. 38 C.F.R. § 3.159(a) (2002); see also Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992). Cardiovascular-renal disease, including hypertension, may be presumed to have been incurred during active military service if it is manifest to a degree of 10 percent within the first year following active service. 38 U.S.C.A. §§ 1101, 1112, 1137 (West 1991); 38 C.F.R. §§ 3.307, 3.309 (2002). Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b) (2002). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d) (2002). Hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. For the purposes of this section, the term hypertension means that the diastolic blood pressure is predominantly 90mm or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm or greater with a diastolic blood pressure of less than 90mm. 38 C.F.R. § 4.104, Note 1, following Code 7101 (2002). Service Medical Records On entrance examination in February 1990, the veteran's heart and vascular system were normal. Blood pressure was 104/64. On periodic examination in September 1990, a physician reported that the veteran's heart and vascular system were normal. Blood pressure was 120/74. An electrocardiogram was done in September 1990. The results were interpreted as showing marked sinus arrhythmia and being otherwise normal. Lipid screening showed an elevated cholesterol of 204 compared to a normal range of 141 to 200. Triglycerides were 97 in a normal range of 30 to 135. HDL Cholesterol was 39 in a normal range of 35 to 70. An accompanying paper notified the veteran that he was at risk of developing coronary heart disease and recommended that he restrict intake of food high in cholesterol. Blood pressure was 120/74. The examination report noted increased cholesterol. Blood pressure was 148/82 in July 1991, 138/70 and 138/72 in September 1991, 144/92 and 117/68 in December 1991, 140/80 and 136/90 in January 1992, and 130/78 and 144/78 in February 1992. An electrocardiogram was done in February 1992. The results were interpreted as normal. Blood pressure was 128/82. Blood pressure was 128/79 and 134/76 in May 1992, 128/68 and 136/80 in June 1992, and 136/62 in December 1992. Blood pressure was 140/76 in February 1993, 140/74 in March 1993, 134/84 in April 1993, 137/75 and 144/74 in May 1993, 131/62 in October 1993 and 137/68, 134/76 and 126/72 in November 1993. In January 1994, blood pressure was 136/74. In February 1994, blood pressure was 110/78 and the assessment was that it was within normal limits. Cholesterol of 175 was also found to be within normal limits. In September 1994, the veteran was seen for left sided chest pain. Three blood pressure readings were within normal limits. His heart had a regular rate and rhythm. There was a II/VI systolic murmur at the aortic area without radiation. There were premature beats and compensatory pauses. Pulses were symmetric and normal. The impression was atypical chest pain secondary to musculoskeletal aches from coughing, and a flow murmur. Electrocardiogram results were interpreted as showing marked sinus arrhythmia and being otherwise normal. The veteran was referred for an echocardiogram with a provisional diagnosis of a benign aortic flow murmur. An echocardiogram was normal. A latter note shows that the assessment was atypical chest pain - resolved and systolic flow murmur. In February 1995, the veteran was noted to have a history of heart murmur. An echocardiogram was normal. The assessment was a functional murmur. On examination in October 1995, there was a II/VI flow murmur. The vascular system was normal. The electrocardiogram was normal. Blood pressure was 118/85. Lipid screening showed an elevated cholesterol of 215 compared to a normal range of 131 to 200. Triglycerides were 121.93 in a normal range of 40 to 210. HDL-RSN was 36.8 a normal range of 30 to 80. LDL was elevated at 154 compared to a normal range of 0 to 129. CH/HDL was elevated at 5.9 compared to a normal range of 0 to 4.5. The summary of defects and diagnoses listed increased cholesterol and increased LDL and no other cardiovascular diagnoses. A summary of care show hypercholesteremia in 1995. A consultation sheet, dated in January 1996, shows that the veteran had been diagnosed with elevated cholesterol. A low cholesterol diet and exercise were recommended. Blood pressure was 144/80 in February 1997 and 146/72 in May 1997. In December 1997, blood pressure was 139/82. Also in December 1997, it was noted that the veteran had a flow murmur, normal echocardiogram, and no documentation of any irregular heartbeat, except incidentally noted during an emergency room visit in September 1994. He was cleared for ergometry testing and aerobic training. In March 1998, the veteran complained of chest pain and shortness of breath. He had a test to investigate his murmur. The results were interpreted by a physician as being clinically and electrically normal maximal Bruce protocol exercise treadmill test. The report of a March 1998 heart evaluation noted the diagnosis of a heart murmur 3 to 4 years earlier. He had a normal echocardiogram in 1995. There was no chest pain or shortness of breath. He rollerbladed and bicycled without problems. The heart had a III/VI systolic murmur, without radiation. Pulses were equal. The assessment was a heart murmur, probably benign - normal echocardiogram. Lipid screening in May 1998 showed cholesterol of 191 within a normal range of 140 to 200. Triglycerides were 145 in a normal range to 200. HDL was 26. LDL was 136. A desirable level was less than 130; borderline high was 130 to 159; and high was greater than 160. CH/HDL ratio was 7.3. Blood pressure was 138/72 in May 1998 and 127/72 in June 1998. Post Service Medical Evidence The report of the February 1999 VA examination shows that the veteran's history was reviewed. Blood pressure was 110/70. Pulse was 68 and regular. The heart had a normal sinus rhythm. No murmurs were heard. Cholesterol was 167 with a desirable range less than 200. The electrocardiogram was borderline with sinus arrhythmia. The pertinent diagnoses were history for functional cardiac heart murmur without evidence of organic cardiovascular disease; and history for transient elevated blood pressure levels without clinical evidence of cardiovascular disease or sustained hypertension. Transient chest wall pain was related to gastroesophageal reflux disease. On the July 2002 VA examination, it was noted that an electrocardiogram showed a sinus arrhythmia. The doctor explained that it was essentially a normal rhythm with a respiratory component and the heart rate slowly changes. It was also noted that the veteran had an echocardiogram which was largely unremarkable, showing no congenital abnormalities. The veteran did have mild tricuspid regurgitation, but that was usually a congenital disorder. The doctor noted that no other abnormalities were seen. He expressed the opinion that the veteran's chest pain was not related to his military duties. He noted that the veteran's gastroesophageal reflux disease was one of the top causes of cardiac type pain. Examination discloses a pulse of 69. Blood pressures were 134/78, 132/78, and 126/80. The heart had a regular rate and rhythm, without third or fourth sounds. There were no rubs, clicks or murmurs. The heart was not lateralized to the lateral aspect of the chest. There was a good, strong carotid upstroke. He did have a sinus arrhythmia heart rate with speed up and slow down with inspiration and expiration. Cholesterol was 165. LDL was 95. HDL was 27. Triglycerides were 215. Echocardiogram, in March 2002, reportedly disclosed sinus tachycardia rate of 101, and nonspecific T- wave abnormalities. The left atrium, right atrium and right ventricle were normal. There was mild mitral valve thickening. The tricuspid valve had trace regurgitation. The final diagnosis (on the echocardiogram) was normal left ventricular systolic function, normal cardiac chamber size, estimated ventricular ejection fraction was 65 percent plus or minus 5 percent. The examination concluded with a diagnosis of atypical chest pain, etiology certain; very unlikely secondary to primary cardiac manifestations. The echocardiogram was said to rule out any congenital abnormalities. The veteran is very young with essentially no risk factors for cardiac disease except for the male sex. The doctor specified that there were "No cholesterol problems." He had a treadmill test which he apparently did very well on. The doctor expressed the opinion that the chest pains could very well be related to the gastroesophageal reflux disease or possibly a component to anxiety with his long history of depression. The physician further opined that chest pain was not related to the veteran's military service and was not cardiac in origin. Analysis The veteran was thoroughly evaluated for cardiovascular pathology during and after service. In addition to numerous examinations, he had extensive testing. While some abnormalities were noted, none of the examiners found any cardiovascular disease. The preponderance of the evidence, as detailed above, shows the heart murmur to be functional in nature and not chronic. It is not a disability resulting from disease or injury for which service connection can be granted. Similarly, there is no diagnosis of hypertension from a medical professional. There are no findings which would meet the regulatory requirement for a diagnosis of hypertension. 38 C.F.R. § 4.104, Note 1, following Code 7101 (2002). While there were a few elevations, the vast majority of blood pressure readings (and the most recent) were within normal limits. The preponderance of the evidence establishes that the veteran does not have hypertension. Cholesterol levels are a reflection of diet and metabolism. The medical personnel during service treated the veteran's cholesterol as a dietary problem and it responded to diet and exercise. None of the medical professionals who have examined he veteran have indicated that this is a disability resulting from disease or injury for which compensation can be paid. In conclusion, we find that the preponderance of the evidence, as detailed above, establishes that the veteran does not have a heart murmur disability due to disease or injury, does not have hypertension, and does not have an organic heart disease manifested by hyperlipidemia (elevated cholesterol). ORDER Service connection for a functional heart murmur is denied. Service connection for hypertension is denied. Service connection for organic heart disease manifested by hyperlipidemia (elevated cholesterol) is denied. GARY L. GICK Veterans Law Judge, Board of Veterans' Appeals IMPORTANT NOTICE: We have attached a VA Form 4597 that tells you what steps you can take if you disagree with our decision. We are in the process of updating the form to reflect changes in the law effective on December 27, 2001. See the Veterans Education and Benefits Expansion Act of 2001, Pub. L. No. 107-103, 115 Stat. 976 (2001). In the meanwhile, please note these important corrections to the advice in the form: ? These changes apply to the section entitled "Appeal to the United States Court of Appeals for Veterans Claims." (1) A "Notice of Disagreement filed on or after November 18, 1988" is no longer required to appeal to the Court. (2) You are no longer required to file a copy of your Notice of Appeal with VA's General Counsel. ? In the section entitled "Representation before VA," filing a "Notice of Disagreement with respect to the claim on or after November 18, 1988" is no longer a condition for an attorney-at-law or a VA accredited agent to charge you a fee for representing you.