Citation Nr: 0617720	
Decision Date: 06/16/06    Archive Date: 06/27/06

DOCKET NO.  01-06 111	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in St. Paul, 
Minnesota


THE ISSUE

Entitlement to service connection for idiopathic 
cardiomyopathy to include as secondary to service-connected 
thyroid hypertrophy. 


REPRESENTATION

Appellant represented by:	Disabled American Veterans


WITNESS AT HEARING ON APPEAL

Appellant


ATTORNEY FOR THE BOARD

Patricia A. Talpins, Associate Counsel 

INTRODUCTION

This matter comes before the Board of Veterans' Appeals (BVA 
or Board) on appeal from a February 2000 rating decision of 
the Department of Veterans Affairs (VA) Regional Office (RO) 
in St. Paul, Minnesota in which the RO denied the benefit 
sought on appeal.  The appellant, who had active service from 
April 1969 to September 1969 and February 1991 to April 1991, 
as well as 20 years of Army Reserve service, appealed that 
decision to the BVA.  Thereafter, the RO referred the case to 
the Board for appellate review.    
 
The Board remanded the case for further development in April 
2004.  Subsequent to the completion of this development, the 
case was returned to the Board for further review.  


FINDINGS OF FACT

1.  All relevant evidence necessary for an equitable 
disposition of the appellant's appeal has been obtained.

2.  Idiopathic cardiomyopathy was not manifested during 
service or for many years following service, and has not been 
established to be causally or etiologically related to 
service or to service-connected thyroid hypertrophy. 


CONCLUSION OF LAW

Idiopathic cardiomyopathy was not incurred in or aggravated 
by active service, may not be presumed to have been so 
incurred, and is not proximately due to or the result of a 
service-connected disease or injury. 38 U.S.C.A. §§ 1101, 
1110, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2002 & 
Supp. 2005); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.306, 3.307, 
3.309, 3.310 (2005).


REASONS AND BASES FOR FINDINGS AND CONCLUSION

A.  The Veterans Claims Assistance Act

With respect to the appellant's claim of entitlement to 
service connection for idiopathic cardiomyopathy, to include 
as secondary to service-connected thyroid hypertrophy, VA has 
met all statutory and regulatory notice and duty to assist 
provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 
5107, 5126 (West 2002 & Supp. 2005); 38 C.F.R. §§ 3.102, 
3.156(a), 3.159, 3.326 (2005).

A letter dated in April 2004 fully satisfied the duty to 
notify provisions. 38 U.S.C.A. § 5103(a); 38 C.F.R. 
§ 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 
(2002).  The appellant was aware that it was ultimately his 
responsibility to give VA any evidence pertaining to his 
claim.  The April 2004 letter informed the appellant that 
additional information or evidence was needed to support his 
service connection claim; and asked the appellant to send the 
information to VA. Pelegrini v. Principi, 18 Vet. App. 112 
(2004)(Pelegrini II).  Although the April 2004 letter was not 
sent prior to the initial adjudication of the appellant's 
claim, this was not prejudicial to him, since he was 
subsequently provided adequate notice, and the claim was 
readjudicated and an additional Supplemental Statement of the 
Case was provided to the appellant in October 2005. 

The appellant's service medical records and VA treatment 
records have been obtained, to the extent possible. 
38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159.  There is no 
indication in the record that any additional evidence, 
relevant to the issue decided herein, is available and not 
part of the claims file.  The appellant was also afforded VA 
examinations in November 1999, July 2001 and July 2003; and a 
VA medical opinion was obtained in March 2002. 38 C.F.R. 
§ 3.159(c)(4).      

Since the Board has concluded that the preponderance of the 
evidence is against the appellant's claim of entitlement to 
service connection, any questions as to the appropriate 
disability rating or effective date to be assigned are 
rendered moot, and no further notice is needed. 
Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006).
B. Law and Analysis

The appellant contends that he is entitled to service 
connection for idiopathic cardiomyopathy.  More specifically, 
he claims that his service-connected thyroid disorder caused 
his idiopathic cardiomyopathy, and that his idiopathic 
cardiomyopathy should be service connected on a secondary 
basis. See July 1999 claim; January 2001 notice of 
disagreement; June 2002 statement.  While viewing the 
evidence in the light most favorable to the appellant in this 
case, the Board finds that the more persuasive and credible 
evidence does not support the appellant's claim; and as such, 
the appeal must be denied.   

Applicable law provides that service connection may be 
granted for a disability resulting from disease or injury 
incurred in or aggravated by active military service. 38 
U.S.C.A. § 1110, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.304 
(2005).  Service connection may also be granted for certain 
chronic diseases, such as organic heart disease, when such 
disease is manifested to a compensable degree within one year 
of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113; 
38 C.F.R. §§ 3.307, 3.309.  In addition, service connection 
may be granted for any disease diagnosed after discharge, 
when all of the evidence, including that pertinent to 
service, establishes that the disease was incurred in 
service. 38 C.F.R. § 3.303(d).  In order to establish service 
connection, a claimant must generally submit (1) medical 
evidence of a current disability, (2) medical evidence, or in 
certain circumstances lay testimony, of service incurrence or 
aggravation of an injury or disease, and (3) medical evidence 
of a nexus or relationship between the current disability and 
the in-service disease or injury. Pond v. West, 12 Vet. App. 
341, 346 (1999).

In addition, service connection may also be established for a 
disability that is proximately due to or the result of a 
service-connected disease or injury. 38 C.F.R. § 3.310(a).  
When service connection is thus established for a secondary 
condition, the secondary condition shall be considered part 
of the original condition. Id.  The United States Court of 
Appeals for Veterans Claims has further held that when 
aggravation of a veteran's nonservice-connected disability is 
proximately due to or the result of a service-connected 
disease or injury, it too shall be service connected for that 
degree of aggravation. Allen v. Brown, 7 Vet. App. 439, 446 
(1995).  Establishing service connection on a secondary basis 
requires evidence sufficient to show: (1) that a current 
disability exists, and (2) that the current disability was 
either (a) caused by or (b) aggravated by a service-connected 
disability. Id.

When, after careful consideration of all procurable and 
assembled data, a reasonable doubt arises regarding service 
origin, such doubt will be resolved in favor of the claimant.  
By reasonable doubt is meant one that exists because of an 
approximate balance of positive and negative evidence that 
does not satisfactorily prove or disprove the claim. 38 
C.F.R. § 3.102.  When the evidence of record is considered 
under the laws and regulations as set forth above, the Board 
is of the opinion that service connection for idiopathic 
cardiomyopathy is not warranted. 

In this case, the evidence reveals that the RO granted 
service connection for thyroid hypertrophy, without other 
symptoms, in a rating decision dated in April 1970.  The 
appellant's initial service medical records noted that he had 
a slightly enlarged thyroid without any good symptoms of 
hyperthyroidism. See service medical records dated in 
September 1969.  A post-service VA examination also did not 
report symptomatology other than an enlarged thyroid. See 
February 1970 examination report.  While several of the 
appellant's Army reserve records reflect that he had a 
diagnosis of hypothyroidism under treatment (See reserve 
records dated in April 1984 and April 1986; February 1983 
report of medical examination; April 1991 report of medical 
history), the Board also observes that these medical records 
specifically report that the appellant had a non-toxic (non-
hyperthyroid) goiter at that time. See March 1982 to May 1982 
reserve medical records.  At the time of his 1991 separation 
from service examination, the appellant was diagnosed with 
thyroid hypertrophy with cause undetermined. April 1991 
examination report.  No reference to hyperthyroidism was 
made. Id. 

As for the appellant's claim for idiopathic cardiomyopathy, 
the evidence does not show (nor does the appellant contend) 
that he developed the disorder in service or within one year 
of separation from service.  In fact, the appellant's service 
medical records are silent as to any complaints, treatment or 
diagnosis involving the appellant's heart.  His service 
separation clinical examinations noted that his heart was 
normal. See August 1969 and April 1991 service separation 
examinations.  In addition, the first medical evidence of 
atrial fibrillation and a diagnosis of idiopathic 
cardiomyopathy occurred in May 1999, eight years after the 
appellant last separated from service. See May 1999 VA 
medical records.  Therefore, service connection for 
idiopathic cardiomyopathy is not warranted on either a direct 
or presumptive basis.  However, the appellant asserts that 
service connection should be granted on a secondary basis, in 
that his idiopathic cardiomyopathy developed secondary to his 
service-connected thyroid hypertrophy.  As will be discussed 
in more detail below, the Board finds that no competent 
evidence of record supports the appellant's contention and 
the appeal for service connection on a secondary basis must 
also be denied.  

In this regard, the Board observes that while the appellant's 
post-service medical records reveal a diagnosis of idiopathic 
cardiomyopathy, none of these records indicate that the 
appellant's cardiomyopathy was either caused by or aggravated 
by his service-connected thyroid disorder. See VA medical 
records dated from April 1970 to September 2002.  In 
addition, none of the VA examiners who physically examined 
the appellant or provided a VA opinion at the RO's request 
opined that the appellant's idiopathic cardiomyopathy was 
secondary to his thyroid disorder. See VA examination reports 
dated in November 1999, July 2001, March 2002 and July 2003.  

In connection with his secondary service connection claim, 
the appellant was originally examined in November 1999.  In 
the history portion of that examination report, the examiner 
indicated that the appellant's enlarged thyroid was 
asymptomatic throughout his adult life; and remained inactive 
until the appellant was started on a drug called Amiodarone 
in June 1999 for atrial fibrillation. See November 1999 
examination report, p. 2.  After performing a physical 
examination, the appellant was diagnosed, among other things, 
with Amiodarone induced hyperthyroidism that was controlled. 
Id., p. 3.  The examiner opined that the appellant's thyroid 
disease was not related to the development of his idiopathic 
cardiomyopathy, but stated that it transiently aggravated his 
cardiac status perhaps with the onset of Amiodarone use. Id. 
 However, the examiner noted that the appellant's 
hyperthyroidism was well controlled and that he believed 
there was no relationship to the appellant's cardiomyopathy 
at present. Id.  

The appellant's representative argues that the November 1999 
examiner's use of the word "aggravated" is a sufficient 
basis upon which to grant service connection in this case. 
See January 2006 statement from the appellant's 
representative, p. 2; April 2004 Appellant's Brief, p. 2.  
Specifically, he contends that the word "aggravated" in 
this opinion indicates that the appellant's service-connected 
thyroid condition permanently increased or worsened the 
appellant's nonservice-connected heart condition. Id.; 
Allen v. Brown, supra at 445, 448 ("when aggravation of a 
veteran's nonservice-connected condition is proximately due 
to or the result of a service-connected condition, such 
veteran shall be compensated for the degree of disability 
(but only that degree) over and above the degree of 
disability existing prior to the aggravation").  However, the 
Board does not agree with this assessment.  

An increase in a preexisting (service connected or 
nonservice-connected) disorder or disease is not the same as 
a temporary or intermittent flare-up of the preexisting 
injury or disease.  The Board observes that a temporary 
flare-up of a preexisting injury or disease is not sufficient 
to be considered "aggravation" unless the underlying 
condition, as contrasted with symptoms, has worsened. Jensen 
v. Brown, 4 Vet. App. 304, 306-307 (1993); Green v. 
Derwinski, 1 Vet. App. 320, 323 (1991); Hunt v. Derwinski, 1 
Vet. App. 292, 297 (1991).  In this case, the November 1999 
examiner noted that the appellant's heart problems were 
transiently aggravated by his thyroid disorder perhaps once 
the appellant started using the drug Amiodarone.  According 
to the Webster's II New College Dictionary, transiently is 
defined as "lasting only a short time." See Webster's II 
New College Dictionary, p. 1171 (2001).  As such, the 
examiner's use of the word "transiently" with the word 
"aggravated" clearly indicates that the examiner intending 
to relay the opinion that the appellant may have experienced 
a temporary or short-term worsening of his cardiac status 
because of the hyperthyroidism the appellant developed after 
taking Amiodarone, but not that it was a permanent worsening.  
Therefore, the examination report does not support the 
appellant's claim of secondary service connection based upon 
aggravation.   

Other VA examination reports contained in the claims file 
also do not assist the appellant's claim.  A July 2001 
examination report, completed without review of the claims 
file and which did not ultimately provide any nexus opinion, 
diagnosed the appellant with status post right 
hemithroidectomy for hyperthyroidism; and noted that the 
appellant's thyroid studies were essentially normal. See July 
2001 examination report, p. 3.   

A March 2002 VA opinion noted that a review of the 
appellant's post-service medical records revealed that he had 
a normal TSH of 0.28 on May 10, 1999 and that he was not on 
any medication for thyroid problems. See March 2002 
examination report, p. 1.  The examiner reported that the 
appellant was then diagnosed in an emergency room with atrial 
flutter on May 24, 1999, at which time he was given 
Amiodarone to control his arrhythmia. Id.  She indicated that 
Amiodarone was well known to cause thyroid abnormalities, 
both hypothyroidism and hyperthyroidism. Id., p. 2.  Shortly 
after being given Amiodarone, the appellant was found to be 
clinically hyperthyroid and was started on another 
medication. Id., p. 1.  The examiner reported that clinical 
notes dated in July 1999 and August 1999 indicated that the 
appellant had an enlarged thyroid gland, but had been 
clinically and biochemically euthyroid until he had been 
started on Amiodarone. Id., p. 2.  Based upon this evidence, 
the examiner stated that there was no evidence that the 
appellant was hyperthyroid prior to beginning the drug 
Amiodarone. Id.  Therefore, the appellant's idiopathic 
cardiomyopathy could not have been caused or aggravated by 
hyperthyroidism since he was not hyperthyroid prior to taking 
Amiodarone.  In addition, the examiner opined that it was not 
likely that the appellant's service-connected thyroid 
enlargement caused his cardiomyopathy. Id.  

Lastly, the appellant was afforded a VA examination in July 
2003, during which  
he stated that he thought he had hyperthyroidism for many 
years. See July 2003 examination report, p. 1.  The appellant 
reported that there were times he had episodes of a rapid 
heart rate lasting up to twenty minutes; and that he never 
saw a physician during these times. Id., p. 2.  The examiner 
performed a physical examination and reviewed the appellant's 
claims file.  In doing so, he noted that there were many 
years of TSH values available for the appellant and that they 
indicated that the appellant had not been hyperthyroid prior 
to June 1999. Id.   The examiner ultimately opined that the 
appellant did not have a heart abnormality either caused by 
or aggravated by his thyroid condition.  In doing so, he 
noted that the appellant's atrial arrhythmias and 
cardiomyopathy were not related to his history of 
asymptomatic goiter in the service; and that the appellant 
was clinically and chemically euthyroid at the time he 
developed atrial fibrillation and flutter and was found to 
have a cardiomyopathy. Id.   

Thus, of the four medical opinions contained in the claims 
file, none support the appellant's claim of entitlement to 
service connection either on a direct or secondary basis.  
Nor is such an opinion contained within the appellant's 
numerous VA medical records.  As such, the Board finds that 
the VA opinions of record are not only persuasive and 
credible, but are also uncontroverted.  Absent a medical 
nexus opinion linking the appellant's idiopathic 
cardiomyopathy to service or his service-connected thyroid 
disorder, the Board cannot find that service connection is 
warranted.  

In making this decision, the Board acknowledges the 
appellant's assertions that his VA medical records show a 
thirty year history of abnormal thyroid functions; and that 
overall his VA records show a history of irregular thyroid 
tests that could be the cause of his atrial fibrillation. See 
June 202 statement, pgs. 1-2.  The Board is also aware of the 
appellant's references to medical records in which it was 
indicated that his atrial flutters were not caused by the 
drug Amiodarone. Id., p. 2.  However, the basis of the 
appellant's claim is that he had hyperthyroidism prior to his 
taking Amiodarone; and that hyperthyroidism caused his 
idiopathic cardiomyopathy.  Yet, the appellant's medical 
records indicate that he was either hypothyroid or euthyroid 
prior to May 1999, at which time he developed hyperthyroidism 
secondary to taking of Amiodarone. See VA medical records 
dated in July 1999 ("Started on amiodarone for A fib ? 
hyperthyroidism"); August 1999 ("Amio hypothyroid") 
("Developed hyperthyroidism 2nd to amiodarone Rx") 
("Hyperthyroidism secondary to Amiodarone administration for