Citation Nr: 1120220 Decision Date: 05/24/11 Archive Date: 06/06/11 DOCKET NO. 07-26 773 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Des Moines, Iowa THE ISSUE Entitlement to service connection for atrial fibrillation secondary to service connected hypertension. ATTORNEY FOR THE BOARD M. G. Mazzucchelli, Counsel INTRODUCTION The Veteran served on active duty from June 1968 to March 1970. This matter comes before the Board of Veterans' Appeals (Board) from an August 2005 rating decision of the Department of Veterans Affairs (VA), regional office (RO) in Sioux Falls, South Dakota. The case is now under the jurisdiction of the Des Moines, Iowa, RO. In October 2009 and again in May 2010, the Board remanded the case for additional development. The Board is satisfied that there has been substantial compliance with the remand directives and it may proceed with review. Stegall v. West, 11 Vet. App. 268 (1998). FINDING OF FACT The competent and probative evidence of record preponderates against a finding that the Veteran's current atrial fibrillation is proximately due to or the result of the Veteran's service-connected hypertension, on either a causation or aggravation basis. CONCLUSION OF LAW Atrial fibrillation is not proximately due, the result of, or aggravated by the Veteran's service-connected hypertension. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.310 (2010). REASONS AND BASES FOR FINDING AND CONCLUSION Notice and Assistance Upon receipt of a complete or substantially complete application for benefits and prior to an initial unfavorable decision on a claim by an agency of original jurisdiction, VA is required to notify the appellant of the information and evidence not of record that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159; Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The notice should also address the rating criteria or effective date provisions that are pertinent to the appellant's claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The RO provided the appellant pre-adjudication notice by letter dated in May 2005. Although the notice provided did not address either the rating criteria or effective date provisions that are pertinent to the appellant's claim, such error was harmless given that service connection for atrial fibrillation is being denied, and hence no rating or effective date will be assigned with respect to this claimed condition. Dingess, 19 Vet. App. at 473. VA has obtained service treatment records, assisted the appellant in obtaining evidence, afforded the appellant physical examinations to assess the current extent of his atrial fibrillation and whether is related to his service connected hypertension, and afforded the appellant the opportunity to give testimony before the Board, although he declined to do so. All known and available records relevant to the issue on appeal have been obtained and associated with the appellant's claims file; and the appellant has not contended otherwise. VA has substantially complied with the notice and assistance requirements and the appellant is not prejudiced by a decision on the claim at this time. Service Connection The Veteran contends that his service connected hypertension has caused or aggravated his atrial fibrillation. He filed a claim for secondary service connection in April 2005. 38 C.F.R. § 3.310 (pertaining to secondary service connection) was amended on September 7, 2006, and that the Veteran was notified of the amendments to 38 C.F.R. § 3.310 in the May 2007 statement of the case. This regulation provides that a disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). This includes any increase in severity of a nonservice-connected disease that is proximately due to or the result of a service-connected disability as set forth in 38 C.F.R. § 3.310(b). See also Allen v. Brown, 7 Vet. App. 439 (1995). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. A March 1966 statement from D.P., M.D., indicates that in 1958 the Veteran was diagnosed with rheumatic fever. During the acute phase, he experienced joint and cardiac complications which cleared during convalescence. On the Veteran's military pre-induction examination in June 1967, a history of rheumatic fever in 1958 was noted. A suspected unproven recurrence in 1960 was noted with no sequalae. No murmur was heard on examination. The heart and vascular systems were clinically evaluated as being normal. On the June 1968 induction examination, no murmur was heard. The heart and vascular systems were clinically evaluated as normal. On the March 1970 separation examination, the heart and vascular systems were clinically evaluated as being normal. An April 1976 private medical report indicates that an electrocardiogram conducted in June 1971 had been interpreted as normal. A June 1971 private medical report shows that no murmurs were heard on examination. The first sound was of good quality. In July 1971, the complete physical examination was negative. On VA examination in April 1976, the Veteran's heart was not enlarged to percussion. There were no murmurs. There was no arrhythmia. There was no arteriosclerosis of the extremities. Chest x-rays revealed that the heart was not enlarged. A July 2001 private medical report shows that an electrocardiogram had revealed sinus bradycardia without acute changes. On examination, the heart had a regular rate and rhythm without murmurs. An April 1984 Mercy Hospital report shows that the Veteran reported suffering from increased fatigue during the last year while playing tennis with associated palpitations and rapid heart rate while relaxing. He was evaluated and the diagnosis was hyperthyroidism. Cardiac examination revealed normal S1 and S2. The diagnosis was hyperthyroidism. A November 1995 private heart clinic report noted that the Veteran had reported an increased incidence of heart palpitations in the past six months. These palpitations tended to occur once or twice per week after exercise. On examination, the Veteran had "significant hypertension with a blood pressure of 140/106," but the Veteran reported that he had never had blood pressure readings over 90 diastolic and the examiner stated that the current blood pressure might just be some anxiety. The preliminary echocardiogram report showed borderline left atrial enlargement and some slight thickening of the mitral valve with sagging but no true prolapse. The examiner did not feel that the Veteran's palpitations were anything to be concerned about, and suspected that they were evidence of premature atrial contractions or premature ventricular contractions. On VA examination in March 2004, it was noted that the Veteran reported the onset of cardiac arrhythmia in the early 1990s. He indicated that he had been told that his arrhythmia could be induced by stress. He had never received treatment for arrhythmia. He reported suffering from an irregular heartbeat at least once a week, but that he had never been treated at such a time. An electrocardiogram in January 2004 showed marked bradycardia. The impressions included a recent diagnosis of paroxysmal atrial fibrillation. A history of rheumatic heart disease was noted. Echocardiogram did not reveal any valvular disease. On a March 2004 VA treatment record, the Veteran presented with palpitations and new onset atrial fibrillation. He reported having palpitations for the past four years or so. A possible trigger may be stress which he was feeling more recently at work with a new boss. An assessment of new onset atrial fibrillation was made with an etiology to include thyroid disease and a past medical history of rheumatic fever as a child. Service connection for hypertension as secondary to posttraumatic stress disorder (PTSD) was granted in a September 2004 rating decision. A January 2005 VA treatment record noted the Veteran had a history of arrhythmia and atrial fibrillation. It was noted that he had "more episodes when BP is up." His hypertension was noted to be under sub optimal control on beta blocker, without side effect but "a little bradycardic." An April 2005 statement from K.W.B., M.D., noted that the Veteran's paroxysmal atrial fibrillation had been a problem for at least four or five years. "He had multiple reasons for developing this disorder, including a remote history of rheumatic fever, prior history of hyperthyroidism, as well as hypertension which is an ongoing problem. More recently, he has had increased frequency and severity of his bouts of atrial fibrillation. Although one cannot be entirely certain of the reason for increased symptoms, I believe it is most directly related to his ongoing hypertension and other factors such as high stress from his posttraumatic stress disorder." On VA examination in June 2005, the Veteran reported that he had recently had his medications adjusted and "his blood pressures have been doing quite well." He reported a history of atrial fibrillation dating back 10 years or so. His most recent episode had occurred the day before the examination. The Veteran had a history of rheumatic fever and of hyperthyroidism with thyroidectomy. On examination, he had blood pressure of 122/80 and regular rate and rhythm of the heart. No murmurs, gallops, or irregular beats were noted. The assessment was hypertension, under good control; paroxysmal atrial fibrillation. The examiner stated that it "did not seem very likely" that the Veteran's hypertension aggravates or causes his arrhythmia. She noted that the Veteran has continued to have episodes of atrial fibrillation even with his current excellent blood pressure control. He also appeared to be chemically hyperthyroid based on his recent TSH level, which would be of concern. The examiner also believed that the Veteran's enlarged left atrium may argue for the presence of rheumatic fever-related mitral valve disease. She concluded that it was "not at least as likely as not that the Veteran's hypertension either caused or aggravated his episodes of paroxysmal atrial fibrillation." A March 2006 statement from the Veteran's treating VA cardiologist stated that the Veteran's atrial fibrillation "may be caused by several reasons. The possibilities being hypertension, previous Graves disease (hyperthyroidism) and may be related to stress." Treatment records from February 2008 and March 2008 noted that the Veteran's hypertension was well-controlled. He continued to be in and out of atrial fibrillation. A VA examination was conducted in June 2010, pursuant to the Board remand. The examiner indicted that the Veteran's claims folder was reviewed in conjunction with the examination. The Veteran reported that he had experienced eight episodes of atrial fibrillation during May 2010. He believed that whenever his blood pressure elevated, his atrial fibrillation episodes increased. He reported a history of rheumatic fever, Grave's disease, with current euthyroid, on medications. He reported that his hypertension was diagnosed in the mid to late 1990s and preceded his diagnosis of atrial fibrillation. He had been treated with ablation in 2008. On examination, his blood pressure was noted as 135/79, 136/84, and 142/87 standing. His pulse was 51. The examiner stated that the Veteran had a number of risk factors for atrial fibrillation. The examiner identified the risk of atrial fibrillation due to hypertension as 1.42, a "relatively small risk." Risk factors in this case for the development of atrial fibrillation were aging, obesity, rheumatic heart disease, hyperthyroidism, and Graves disease. He also stated that TSH levels below 0.5 also produced a much greater increase in atrial fibrillation even with normal thyroid hormone levels. The examiner noted that the Veteran's TSH level was measured at 2.32 in August 2009 and 0.28 on April 30, 2010, with the Veteran reporting his atrial fibrillation episodes increasing from two to three times per month to eight times during May 2010. The examiner stated that the Veteran's blood pressure remained normal during this period, "the only change was diminished TSH resulting in subclinical hyperthyroidism. It is noted in the C&P exam of 6-7-05, similar TSH levels well below 0.5 were also associated with increased AF events. The hyperthyroidism resulted in the increased AF events, not the blood pressure, as is predicted in the medical literature." The examiner again stated that "hypertension is a small risk factor associated with AF. In this case, the patient's risk factor of obesity alone (2.32) exceeds his risk factor with respect to hypertension (1.42). Additional factors in this case, Graves disease, subclinical hyperthyroidism, rheumatic heart disease, age, in addition to obesity result in the risk factor of hypertension alone to be negligible. This patients' AF is much less likely than not, much less than 50/50, associated with hypertension, either as an etiology, aggravation, or exacerbation. AF was not caused by his hypertension." The weight of the medical evidence of record is against a finding that the Veteran has atrial fibrillation that is caused by or aggravated by his service-connected hypertension. The VA examinations of record have specifically found it less likely than not that the Veteran's atrial fibrillation is related to his service connected hypertension. The June 2010 VA examiner provided a thorough review of the evidence and risk factors associated with the Veteran's atrial fibrillation and showed that the Veteran's increase in episodes of atrial fibrillation was strongly associated with his TSH levels and not with his blood pressure readings. Both that examiner and the June 2005 VA examiner noted that the Veteran has continued to have episodes of atrial fibrillation even while his blood pressure has been under good control. While Dr. B.'s April 2005 statement attributed the recent increase in the Veteran's episodes of atrial fibrillation to his hypertension, his opinion did not provide any basis for that conclusion in the form of any analysis of the Veteran's blood pressure readings as associated with his atrial fibrillation episodes. The March 2006 VA cardiologist's statement that the Veteran's atrial fibrillation "may be" associated with his hypertension (among other factors) is equivocal and does not constitute probative evidence on the question of etiology or aggravation. As the June 2005 and June 2010 VA examiners provided rationale and cited to specific evidence in the file as support for their opinions, they are found to be persuasive. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). In light of the thoroughness of the June 2005 and June 2010 VA examination reports and opinions provided, the Board will afford them significantly more probative weight in its determination than the unsubstantiated opinion provided in the April 2005 statement discussed above. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (it is the responsibility of the Board to assess the credibility and weight to be given the evidence). Thus, the Board finds that the medical evidence as a whole fails to substantiate that the Veteran has atrial fibrillation that is related to his service connected hypertension. The Veteran has also provided his own statements to the effect that his atrial fibrillation is related to his hypertension. Neither the Board nor the Veteran is competent to supplement the record with unsubstantiated medical conclusions. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991); Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). The Veteran himself may believe that his atrial fibrillation is related to his hypertension. However, these questions of etiology and diagnosis involve complex medical issues that he is not competent to address. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The evidence in this case is not so evenly balanced so as to allow application of the benefit-of-the-doubt rule as required by law and VA regulations. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The preponderance is against the Veteran's claim and it must be denied. ORDER Service connection for atrial fibrillation secondary to service connected hypertension is denied. ____________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs