Citation Nr: 0811638	
Decision Date: 04/09/08    Archive Date: 04/23/08

DOCKET NO.  05-03 459A	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in St. 
Petersburg, Florida


THE ISSUE

Entitlement to service connection for a heart disorder, to 
include a coronary artery anomaly.


REPRESENTATION

Appellant represented by:	The American Legion


WITNESS AT HEARING ON APPEAL

Appellant


ATTORNEY FOR THE BOARD

A. Barone, Associate Counsel


INTRODUCTION

This matter is before the Board of Veterans' Appeals (BVA or 
Board) on appeal from a rating decision, dated in March 2004, 
of the Department of Veterans Affairs (VA) Regional Office 
(RO) in Saint Petersburg, Florida, that denied the benefit 
sought on appeal.  The veteran, who had active service from 
January 1964 to January 1987, appealed that decision to the 
BVA and the case was referred to the Board for appellate 
review.



FINDINGS OF FACT

1.  The veteran's coronary artery anomaly of having only a 
single coronary artery is a congenital defect, and is not a 
disease or injury for the purposes of entitlement to VA 
compensation benefits.

2.  The veteran's current cardiomyopathy was first manifested 
many years after service, and no chronic acquired heart 
disorder is shown to be causally or etiologically related to 
service.



CONCLUSION OF LAW

A heart disorder, to include a coronary artery anomaly, was 
not incurred in or aggravated during active service, nor may 
one be presumed to have been so incurred.  38 U.S.C.A. 
§§ 1101, 1110, 1112, 1113, 1131, 1137, 1153, 1154, 5103, 
5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 
3.304, 3.307, 3.309 (2007).



REASONS AND BASES FOR FINDINGS AND CONCLUSION

Before addressing the merits of the appellant's claim on 
appeal, the Board is required to ensure that the VA's "duty 
to notify" and "duty to assist" obligations have been 
satisfied.  See 38 U.S.C.A. §§ 5103, 5103A (West 2002); 
38 C.F.R. § 3.159 (2007).  The notification obligation in 
this case was accomplished by way of a letter from the RO to 
the appellant dated in January 2004.  The Board notes that 
information concerning the effective date that could be 
assigned should the benefit sought be granted, Dingess v. 
Nicholson, 19 Vet. App. 473 (2006), was not provided until a 
subsequent letter dated June 2006.  The June 2006 letter was 
arguably untimely; however, since this decision affirms the 
RO's decision, the appellant is not prejudiced by any defect 
in the timing of providing him that further information.

The RO also provided assistance to the appellant as required 
under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c), as 
indicated under the facts and circumstances in this case.  
The appellant has not made the RO or the Board aware of any 
additional evidence that needs to be obtained in order to 
fairly decide this appeal, and has not argued that any error 
or deficiency in the accomplishment of the duty to notify and 
duty to assist has prejudiced him in the adjudication of his 
appeal.  Mayfield v. Nicholson, 19 Vet. App. 103 (2005), 
rev'd on other grounds, No. 05-7157 (Fed. Cir. Apr. 5, 2006).  
Therefore, the Board finds that the duty to notify and duty 
to assist have been satisfied and will proceed to the merits 
of the appellant's appeal.

The veteran claims entitlement to service connection for a 
heart disorder.  Applicable law provides that service 
connection will be granted for disability resulting from an 
injury suffered or disease contracted in line of duty, or for 
aggravation of a preexisting injury suffered or disease 
contracted in line of duty, in the active military, naval, or 
air service.  38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303.  
However, that an injury or disease occurred in service alone 
is not enough; there must be chronic disability resulting 
from that injury.  If there is no showing of a resulting 
chronic condition during service, then a showing of 
continuity of symptomatology after service is required to 
support a finding of chronicity.  38 C.F.R. § 3.303(b).  
Additionally, for veterans who have served 90 days or more of 
active service during a war period or after December 31, 
1946, certain chronic disabilities, such as cardiovascular-
renal disease, are presumed to have been incurred in service 
if manifest to a compensable degree within one year of 
discharge from service.  38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. 
§§ 3.307, 3.309.  Service connection may also be granted for 
any injury or disease diagnosed after discharge, when all the 
evidence, including that pertinent to service, establishes 
that the disease or injury was incurred in service.  38 
C.F.R. § 3.303(d).

Generally, to prove service connection, the record must 
contain:  (1) Medical evidence of a current disability, (2) 
medical evidence or in certain circumstances, lay testimony, 
of an inservice incurrence or aggravation of an injury or 
disease, and (3) medical evidence of a nexus or a 
relationship between a current disability and the inservice 
disease or injury.  Pond v. West, 12 Vet. App. 341 (1999); 
Caluza v. Brown, 7 Vet. App. 498 (1995).

This case involves a substantial quantity of pertinent 
medical evidence, including numerous diagnostic testing 
reports involving the veteran's heart function during his 
years of active duty service.  Significantly, the record 
features three competent medical opinions addressing the 
veteran's heart-related medical history as it relates to his 
contentions in this appeal: that a chronic acquired heart 
disorder was first manifested during service or within a year 
of discharge from service, or that an acquired heart disorder 
was permanently aggravated during service.  It is clear from 
the record that the veteran complained of pertinent symptoms 
and received medical attention concerning his cardiac 
function on numerous occasions during service.  The record 
contains ample documented evidence of medical attention 
concerning cardiac function during service, dating from as 
early as 1967 through the veteran's retirement from service.  
There is no controversy in this case regarding this treatment 
history.  Rather, this appeal features a question of whether 
any current chronic acquired heart disorder is etiologically 
related to any instance of cardiac symptomatology during 
service, or was permanently aggravated during service, or is 
otherwise etiologically linked to service.

After review of the entire claims folder, and in 
consideration of the competent medical opinions interpreting 
the significant medical history and documented diagnostic 
testing, the Board finds that the preponderance of the 
evidence weighs against service connection in this case.  The 
Board has reviewed the pertinent medical history, including 
the service medical records and post-service medical records 
showing treatment and diagnostic testing regarding the 
veteran's cardiac function.  In light of the specialized 
nature of the available cardiac treatment records, and the 
complicated medical questions in this case, the evidence the 
Board must most directly evaluate features the set of recent 
medical opinions interpreting and explaining the veteran's 
documented cardiac medical history.  The Board cannot 
directly interpret the contemporaneous specialized cardiac 
diagnostic information contained in the record without 
medical expertise.  It is well-settled that in its decisions, 
the Board may not rely upon its own unsubstantiated medical 
opinion.  Allday v. Brown, 7 Vet. App. 517 (1995); Godfrey v. 
Brown, 7 Vet. App. 398 (1995); Traut v. Brown, 6 Vet. App. 
495 (1994); Colvin v. Derwinski, 1 Vet. App. 171 (1991).

The Board notes that the veteran has submitted a private 
medical opinion in support of his claim dated in August 2003.  
In this statement, the veteran's private cardiologist 
expresses that he first treated the veteran in 1998 when the 
veteran presented with chest discomfort.  According the 
statement, in 1998 the veteran "had mild left ventricular 
dysfunction and no significant coronary artery disease."  
Stemming from that, the veteran "has been carrying the 
diagnosis of congestive cardiomyopathy with mild left 
ventricular dysfunction since that time."  The cardiologist 
explains that, despite the fact that the diagnosis dates from 
1998, "prior records from 1982 demonstrate an abnormal EKG, 
chest pain and shortness of breath even at that time."  
Furthermore, the cardiologist observes that "An EKG back as 
far as 1975 likewise demonstrates abnormalities which [have] 
been persistent since then."  The cardiologist's letter 
concludes, significantly, that "It is entirely conceivable 
that his problem has been going on at least since 1975."

The Board has considered this competent medical statement 
which suggests that veteran may have developed a chronic 
acquired heart disease during his period of active service.  
The Board notes that the cardiologist's factual assertions 
are consistent with the record.  However, although the 
evidence is competent, the Board is unable to accord the 
August 2003 cardiologist's statement significant probative 
value in support of the veteran's claim.  The August 2003 
statement can be accorded no substantial probative value 
because its conclusion is speculative in nature, identifying 
a mere possibility rather than any probability.  See Bostain 
v. West, 11 Vet. App. 124, 127-28, quoting Obert v. Brown, 5 
Vet. App. 30, 33 (1993) (medical opinion expressed in terms 
of 'may' also implies 'may or may not' and is too speculative 
to establish medical nexus); see also Warren v. Brown, 6 Vet. 
App. 4, 6 (1993) (doctor's statement framed in terms such as 
'could have been' is not probative).  See also Libertine v. 
Brown, 9 Vet. App. 521, 523 (1996); Beausoleil v. Brown, 8 
Vet. App. 459, 463 (1996); Tirpak v. Derwinski, 2 Vet. App. 
609, 611 (1992); see also 38 C.F.R. § 3.102 (describing the 
concept of reasonable doubt in adjudicating service 
connection claims as not being one arising from pure 
speculation or remote possibility).  Thus, the conclusion of 
the August 2003 cardiologist's statement that "It is 
entirely conceivable that his problem has been going on at 
least since 1975" is not a significantly probative medical 
demonstration of a heart pathology etiologically related to 
service.

An April 2005 VA examination report is of record.  This 
report expressly reflects review of the claims folder to 
include the veteran's pertinent documented medical history.  
This report shows that upon personal examination of the 
veteran, diagnoses of congestive cardiomyopathy, 
dyslipidemia, and essential hypertension were noted.  The 
examiner acknowledged the August 2003 cardiologist's letter 
suggesting that it is "conceivable" that a chronic heart 
pathology was etiologically related to service, and 
independently concluded that "It would be speculative to 
state that the veteran had cardiomyopathy during this 
military service as there is no definite diagnosis made of 
this during his military duty."  The examiner further noted 
that the veteran's service medical records indicate 
"nonspecific changes on his EKG" and refrained from further 
comment as the April 2005 examiner acknowledged that she was 
not a cardiologist.

As documented in the claims folder, in February 2006 the RO 
requested that the claims folder be forwarded to a 
cardiologist specialist for appropriate review and a 
competent etiology opinion.  The Board notes, in passing, 
that under the presumption of administrative regularity of 
government actions, it may be presumable that the RO's 
documented February 2006 request for a VA cardiologist's 
review of the claims folder resulted in proper delivery of 
the request to be completed by a VA cardiologist, in the 
absence of specific evidence to the contrary.  See, e.g., 
Mindenhall v. Brown, 7 Vet. App. 271, 274 (1994).  See also 
Schoolman v. West, 12 Vet. App. 307, 310 (1999) (''clear 
evidence to the contrary' is required to rebut the 
presumption of regularity.').  Following the RO's February 
2006 request, the resulting April 2006 VA examiner's report 
does not expressly confirm that the author is a cardiologist.  
As discussed below, however, additional development has been 
accomplished which reduces the significance of this ambiguity 
in the record.  The Board finds that the outcome of this case 
is unaffected regardless of whether the April 2006 VA 
examiner's report is considered to be the opinion of a 
medical doctor, or is considered to be especially probative 
as the opinion of a cardiology specialist.

The April 2006 report features a thorough discussion of the 
documented medical evidence of record in the claims folder.  
The April 2006 report notes that the veteran left the service 
in 1987, and subsequently presented to his private 
cardiologist in 1998 with symptoms leading to diagnosis of 
"a mild non-ischemic cardiomyopathy."  The April 2006 
report addresses the pertinent assertion that "during this 
period his EKG apparently demonstrated the same changes that 
were noted as early as 1967,"  and acknowledges the August 
2003 private cardiologist's statement "which implied that 
his EKG changes, that were present while he was in the Air 
Force, could have represented an early phase of his current 
cardiomyopathy...."  In this regard, the doctor authoring the 
April 2006 VA examiner's report suggests that the veteran's 
private cardiologist "did not have access to his full 
service medical record and therefore perhaps was unaware of 
the thorough cardiac evaluation this patient underwent in 
1982, when he had the same EKG changes that he apparently has 
now."

Significantly, the April 2006 VA examiner's report offers the 
opinion that "I personally do not think his documented EKG 
changes (that ...were likely present at the time of enlistment) 
present as early as 1967 were representative of a 
cardiomyopathic condition that later became ... apparent in 
1998."  In the April 2006 report, the VA examiner clearly 
explains that "There is clearly no cardiomyopathy present at 
the time of his thorough cardiac evaluation in 1982 and to 
say that the patient had a service connected cardiac 
condition, is entirely speculative without any corroborating 
evidence (less than likely)."  

The April 2006 VA doctor's report draws several highly 
significant conclusions.  Primarily, the report states "I do 
not think that this patient has a service connected cardiac 
condition."  This conclusion is explained with a rationale 
including that, "his EKG is likely congenital in origin or 
certainly was present prior to his enlistment in the service, 
but regardless he had an extreme[ly] thorough cardiac 
evaluation in 1982 to evaluate these EKG changes as well as 
atypical chest pain."  The VA examiner further explains that 
"This [1982] evaluation was entirely normal and I do not 
think that his mild cardiomyopathy that he has apparently 
developed as documented in 1998 represents anything that 
would have been present or related to his military service."

In the Board's view, the April 2005 VA examination report is 
probative medical evidence to the extent it presents a 
medical opinion, informed by a thorough review of the medical 
evidence of the record, that any suggested link between a 
current heart disability and military service would be 
speculative.  The April 2006 VA examiner's report, although 
not clearly identifying itself as a cardiologist's report, 
does supplement the record with another competent doctor's 
thorough discussion of all of the pertinent evidence of 
record and finds that no current acquired heart disease is 
causally linked to military service.  The Board notes that 
the factual assertions in both reports are consistent with 
what is shown in the record.

The Board requested a Veterans Health Administration (VHA) 
medical opinion in September 2006.  The veteran was advised 
of the request that same month.  The Board sought this 
additional development to add necessary clarity to the record 
as the April 2006 examination report leaves some confusion as 
to whether the author was a cardiologist.  Also, there 
remained pertinent unaddressed medical questions in need of 
more adequate discussion, including regarding whether any 
cardiac diagnosis which may have pre-existed service was an 
acquired disease aggravated during service or, rather, was 
congenital in nature.

The resulting October 2007 VHA cardiologist's letter presents 
a probative and persuasive competent analysis of the evidence 
in this case.  The letter contains a thorough and detailed 
discussion of the documented medical evidence of record, and 
reflects very careful consideration of the claims folder.  In 
presenting the cardiologist's analysis and conclusions, the 
letter first addresses the question of whether the veteran 
entered service with any cardiac defect, abnormality, or 
disease.  The VHA cardiologist explains that the veteran 
entered the service with the coronary anomaly of having only 
a single coronary artery, a left coronary artery in this 
case.  Significantly, the VHA cardiologist explains in 
definitive terms that the single coronary artery "is a 
congenital abnormality."  The abnormality "generally does 
not affect coronary blood flow."  Moreover, "the multiple 
stress tests that the patient had confirm that there was no 
obstruction to coronary blood flow."  The letter goes on to 
refer to the specifics of the veteran's documented EKG 
results from March 1967; "the ST and T wave changes were 
present on that EKG and further EKG over the years during the 
service showed no change."

The October 2007 VHA cardiologist's letter continues on to 
address whether any cardiac diagnosis underwent an increase 
in severity during service.  In this regard, the VHA 
cardiologist notes that "The EKG changes had been thoroughly 
investigated during service (exercise EKG stress tests, 
coronary angiography, thallium testing and 
echocardiography)."  The VHA cardiologist cites that "No 
cause could be found for these changes and the heart function 
was good."  On this point, the cardiologist concludes that 
"There has been no change or deterioration during service."

The October 2007 VHA cardiologist's letter finally addresses 
whether any currently diagnosed cardiac defect, abnormality, 
or disease is etiologically related to symptomatology shown 
in service medical records or whether any current cardiac 
pathology had its onset during service.  The VHA 
cardiologist's final conclusion is that no currently 
diagnosed cardiac disease had clinical onset during service.  
The VHA letter clearly explains the rationale that "The 
chest pain that the patient had been complaining of during 
service was non-cardiac in origin and it is not causally or 
etiologically related to his current cardiac diagnosis of 
idiopathic congestive cardiomyopathy."  The cardiologist's 
letter concludes that "His cardiomyopathy did not have 
clinical onset during service or in the post service period 
ending January 1988."

The Board views that October 2007 VHA cardiologist's letter 
as the most probative evidence in this case.  This competent 
medical statement from a cardiology specialist, informed by a 
thorough review and discussion of the pertinent evidence in 
the claims folder, presents a persuasive rationale for the 
medical opinion weighing against this claim.  The Board notes 
that the cardiologist's factual assertions are consistent 
with the record.  The most significant contrary evidence of 
record is the August 2003 private cardiologist's statement, 
but the August 2003 statement merely indicates a possibility 
of an etiological link between current heart disease and 
service, based upon a rationale vaguely referencing the fact 
that there were 'abnormal' EKG results during service.  The 
October 2007 VHA letter discusses the service medical 
records, and broader medical history, in significant detail 
to conclude that the documented medical evidence does not 
support any such etiological link.

To the extent that the veteran's heart disorder has been 
characterized as a congenital defect, congenital or 
developmental defects are not diseases or injuries within the 
meaning of applicable legislation.  38 C.F.R. §§ 3.303(c), 
4.9 (2007).  In the absence of superimposed disease or 
injury, service connection may not be allowed for a 
congenital defect.

The competent medical evidence of record indicates that no 
current heart disorder is etiologically related to active 
service.  A claimant has the responsibility to present and 
support a claim for benefits under laws administered by the 
VA, 38 U.S.C.A. § 5107(a), and the appellant was clearly 
advised of the need to submit medical evidence of a 
relationship between a current heart disorder and service.  
While the appellant is clearly of the opinion that his heart 
disorder is related to service, as a lay person, the 
appellant is not competent to offer an opinion that requires 
specialized training, such as the etiology of a medical 
disorder or the disability.  Espiritu v. Derwinski, 2 Vet. 
App. 492, 494 (1992).  

Accordingly, the Board concludes that service connection for 
a heart disorder, to include a coronary artery anomaly, is 
not established.  The preponderance of the evidence is 
against the claim for service connection and the benefit of 
the doubt rule is inapplicable.  38 U.S.C.A. § 5107.


ORDER

Service connection for a heart disorder, to include a 
coronary artery anomaly, is denied.



____________________________________________
RAYMOND F. FERNER
Acting Veterans Law Judge, Board of Veterans' Appeals



 Department of Veterans Affairs