Citation Nr: 1316376 Decision Date: 05/17/13 Archive Date: 05/29/13 DOCKET NO. 08-06 163 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUE Entitlement to service connection for a heart disability manifested by an irregular heartbeat. ATTORNEY FOR THE BOARD T. Wishard, Counsel INTRODUCTION The Veteran had active military service from August 1974 to April 2004. This matter comes before the Board of Veterans' Appeals (Board) from a March 2007 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO) in Muskogee, Oklahoma. This matter was previously before the Board in September 2009, August 2011, and January 2013 and was remanded for further development. It has now returned to the Board for further appellate consideration. The Board finds that the Appeals Management Center (AMC) substantially complied with the mandates of the remands, and the Board will proceed to adjudicate the appeal. FINDINGS OF FACT 1. There has been no demonstration by competent medical, nor competent and credible lay, evidence of record, that the Veteran has a heart disability, to include a disability manifested by irregular heartbeats. 2. The competent credible evidence of record reflects that the Veteran does not have a heart disability. CONCLUSION OF LAW A heart disability was not incurred in, or aggravated by, active service, and may not be presumed to have been so incurred or aggravated. 38 U.S.C.A. §§ 1101, 1110, 1154, (West 2002); 38 C.F.R. § 3.303, 3.304, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also 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); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Notice was provided to the Veteran in May 2006. VA has a duty to assist the Veteran in the development of the claim. The claims file includes service treatment records (STRs), VA and private medical records, and the statements of the Veteran in support of his claim. QTC and VA examinations and opinions were obtained in August 2006, November 2011 with an October 2012 addendum, and in February 2013. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the Veteran has been provided with a more than adequate examination and opinion. The February 2013 examination report reflects that the examiner considered the entire claims file, to include the Veteran's STRs and post-service clinical records, and diagnostic testing. The February 2013 report provides a thorough rationale for the opinion provided. Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to the claim. Essentially, all available evidence that could substantiate the claim has been obtained. Legal Criteria Establishing service connection generally requires medical evidence or, in certain circumstances, lay evidence of the following: (1) A current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed.Cir.2007); Hickson v. West, 12 Vet. App. 247 (1999); Caluza v. Brown, 7 Vet.App. 498 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). For some "chronic diseases," presumptive service connection is available. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. With "chronic disease" shown as such in service (or within the presumptive period under § 3.307), so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). For the showing of a 'chronic disease' in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Id. If not manifest during service, where a veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, and the 'chronic disease' became manifest to a degree of 10 percent within 1 year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307. The term "chronic disease", whether as shown during service or manifest to a compensable degree within a presumptive window following service, applies only to those disabilities listed in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. Feb. 21, 2013). Organic diseases of the nervous system are included in 38 C.F.R. § 3.309(a). In each case where service connection for any disability is being sought, due consideration shall be given to the places, types, and circumstances of such Veteran's service as shown by such Veteran's service record, the official history of each organization in which such Veteran served, such Veteran's medical records, and all pertinent medical and lay evidence. 38 U.S.C.A. § 1154(a) (West 2002). Analysis The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the medical evidence pertinent to the claim on appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the U.S. Court of Appeals for the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim. The Veteran avers that he has heart disability manifested by an irregular heartbeat. An essential element for service connection is a current disability. The Board finds, a discussed below, that this element has not been met. The February 2013 VA examination report reflects the opinion of the examiner as follows: The Veteran does not have a diagnosed heart problem. He has an abnormal EKG finding (left axis deviation) which is a normal variant. The service medical records show that on April 15th of 1986 he had EKG which showed Normal sinus rhythm, sinus bradycardia and early repolarization. He had a holter monitor done on 17th of April 1986 which was normal. All the EKGs done in service showed early repolarization with bradycardia. The term early repolarization (ER), also known as "J-waves" or "J-point elevation", has long been used to characterize a QRS-T variant on the electrocardiogram (ECG). Most literature defines ER as being present on the ECG when there is a J-point elevation of ?0.1mV in two adjacent leads with either a slurred or notched morphology. Historically, ER has been considered a marker of good health because it is more prevalent in athletes, younger persons, and at slower heart rates. While some level of increased risk of sudden cardiac death has been reported in persons with ER, the relatively high prevalence of the ER pattern in the general population (5 to 13 percent) in comparison to the incidence of idiopathic VF (ventricular fibrillation) (approximately 10 cases per 100,000 population) means that the ER pattern will nearly always be an incidental ECG finding with no clinical implications. The Veteran has a normal variant on EKG, has no heart problems, no symptomatology which could be attributed to his heart. Had a normal Holter monitor in service. The EKG findings are not diagnostic of any cardiac disorder. On todays EKG the only abnormality he has is left axis deviation which is a normal variant, with no underlying heart disease. As a service connection claim requires, at a minimum, medical evidence of a current disability, the Veteran's claim for service connection for a heart disability is not warranted in this case. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The Board acknowledges the Veteran's contentions that he tires more easily due to his irregular heartbeat, and that the symptoms occur intermittently, as often as twice a week and last for one minute. Although the Veteran is competent to report feeling tired and feeling his heartbeat, he has not been shown to have the training, experience, or knowledge necessary to make a competent determination that any feelings of tiredness are due to his normal variant heartbeat. Moreover, the Board finds that disability determinations with regard to the rhythm and rate of the heart, which involve the specialty of cardiology, are outside the realm of a lay person. The Board also acknowledges the evidence of record which reflects that the Veteran was suffering from an irregular heart beat since service (See 2006 QTC examination report) and the STRs which reflect abnormal EKGs, mild left axis deviation, and/or sinus bradycardia (e.g. 1984, 1986, 1996, and 2003). The Board acknowledges the November 2011 VA examination report in which the examiner stated that the Veteran's irregular heartbeat is at least as likely as not incurred in, or caused by, service because the Veteran has a current EKG abnormality and also had the abnormality first identified and diagnosed in service. However, the November 2011 VA examiner did not diagnosis an actual disability. In her addendum, the examiner stated that there is "no current history, symptoms, diagnosis or treatment of a cardiac condition. In review of the record, the EKG findings alone do not constitute a cardiac condition." In addition, as discussed in detail by the 2013 VA examiner, the Veteran's heartbeat is a normal variant and is not a disability, or a symptom of a disability. (See VA examination reports.) The Board has also considered the July 2006 private record from The Heart Clinical Associates, which reflects that that the Veteran was stressed on the Bruce protocol in which he exercised for 10 minutes and 29 seconds. His resting EKG showed normal rhythm with nonspecific ST T-wave changes. His stress ECG did not reveal any new changes of ischemia. He did not have any chest pain. In addition, a July 2006 private record from Medical Support Systems, Inc. reflects that chest views of the Veteran revealed that the cardiomediastinal silhouette was normal. Several VA clinical records also reflect that the Veteran's heart rate and rhythm were normal upon examination and that no murmurs were heard (e.g. June 2007, August 2008, and June 2009 VA clinical records.) In sum, the competent clinical evidence of record reflects that the Veteran does not have a disability of the heart; thus, service connection is not warranted. The evidence includes numerous clinical records and reports, to include findings of x-rays, extensive diagnostic testing, a physical examination, and a thorough clinical opinion. The Board has considered the doctrine of giving the benefit of the doubt to the appellant, under 38 U.S.C.A. § 5107 (West 2002), and 38 C.F.R. § 3.102 (2012), but does not find that the evidence is of such approximate balance as to warrant its application. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). ORDER Entitlement to service connection for a heart disability manifested by an irregular heart beat is denied. ____________________________________________ MILO H. HAWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs