Citation Nr: 1324724 Decision Date: 08/02/13 Archive Date: 08/13/13 DOCKET NO. 05-00 164 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for a heart disorder. 2. Entitlement to service connection for a disorder manifested by chronic chest pain. REPRESENTATION Appellant represented by: Virginia Department of Veterans Services ATTORNEY FOR THE BOARD T. M. Gillett, Counsel INTRODUCTION The Veteran served on active duty from November 1976 to May 1986. This matter came before the Board of Veterans' Appeals (Board) on appeal from a July 2003 decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. By that rating action, the RO determined that new and material evidence had not been received to reopen previously denied claims for service connection for 'chest pain' and a heart condition. In an August 2007 decision, the Board reopened the claims and remanded the case for further development. In November 2009, April 2011, and September 2012, the Board again remanded the claims to the Appeals Management Center (AMC) for additional development. FINDINGS OF FACT 1. The Veteran does not have a current heart disorder that began during service or is related to any incident of service. 2. The Veteran does not have a current disorder manifested by chronic chest pain that began during service or is related to any incident of service. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a heart disorder have not been met. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137, 5103, 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2012). 2. The criteria for entitlement to service connection for a disorder manifested by chronic chest pain have not been met. 38 U.S.C.A. §§ 1101, 1131, 1137, 5103, 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Introductory Matters In this decision, the Board will discuss the relevant law which it is required to apply. This includes statutes enacted by Congress and published in Title 38, United States Code ("38 U.S.C.A."); regulations promulgated by VA under the law and published in the Title 38 of the Code of Federal Regulations ("38 C.F.R."), and the precedential rulings of the United States Court of Appeals for the Federal Circuit (Federal Circuit) (as noted by citations to "Fed. Cir.") and the United States Court of Appeals for Veterans Claims (Court) (as noted by citations to "Vet. App."). The Board is bound by statute to set forth specifically the issue under appellate consideration and its decision must also include separately stated findings of fact and conclusions of law on all material issues of fact and law presented on the record, and the reasons or bases for those findings and conclusions. 38 U.S.C.A. § 7104(d) (West 2002 & Supp. 2012); see also 38 C.F.R. § 19.7 (2012) (implementing the cited statute); see also Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999); Gilbert v. Derwinski, 1 Vet. App. 49, 56-57 (1990) (the Board's statement of reasons and bases for its findings and conclusions on all material facts and law presented on the record must be sufficient to enable the claimant to understand the precise basis for the Board's decision, as well as to facilitate review of the decision by courts of competent appellate jurisdiction. The Board must also consider and discuss all applicable statutory and regulatory law, as well as the controlling decisions of the appellate courts). Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 ("VCAA") describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify a veteran and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim, and to indicate which information and evidence VA will obtain and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The notice must be provided to the veteran prior to the initial adjudication of his or her claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). VCAA notice requirements apply to all five elements of a service connection claim: (1) veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). VA satisfied its duty to notify the Veteran by issuing a notice letter in August 2007. In this notice letter, VA informed the Veteran about the information and evidence not of record that was necessary to substantiate the claims; the information and evidence that VA would seek to provide; the information and evidence the Veteran was expected to provide; and the information regarding the assignment of ratings and effective dates required by Dingess. VA sent the required VCAA notice letter after initially deciding the appellant's claim; the August 2007 letter was thus untimely. VA cured this timing defect later, however, by readjudicating the appellant's claim in a SSOC issued in August 2008. Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). The duty to assist provisions of the VCAA have been met. The claims file contains service treatment records, reports of post-service medical treatment, and reports of VA medical examinations provided in June 2008, July 2008, May 2011, and February 2013, and a VA psychiatric examination provided in May 2013. The Board notes that the Veteran has indicated being told by doctors of diagnoses that might support his claim for service connection for a disorder manifested by chronic chest pain. However, although he was provided with a release form to allow VA to procure these records from this unnamed examiner, attached to an October 2012 VCAA notice letter, the Veteran did not return the release form as requested. As the Veteran filed his petition reopen his claim of service connection for these issues in February 2003, over the previous 10 years, VA has notified the Veteran on four occasions of the need to provide release forms or, at least, basic information about examiners to allow VA to procure outstanding records. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) (holding that the duty to assist is not a one-way-street and that a veteran must provide information that will allow VA to assist him). As the Veteran did not provide either release forms or contact information that would allow VA to procure records from these examiners, despite being advised to do so on multiple occasions, the Board finds that it has fulfilled its duty to assist the Veteran in procuring those examiners' records. See 38 C.F.R. § 3.159(e)(2) (where claimant does not provide release for records, VA's duty to assist is fulfilled where the claimant is asked to provide the records). In August 2007, the Board remanded the Veteran's claims to the AMC for the issuance of a VCAA notice letter, the procurement of any additional treatment records, and the provision of a VA medical examination to determine the nature and etiology of the claimed heart disorder and disorder manifested by chronic chest pain. The record indicates that the AMC provided the VCAA notice letter and provided the Veteran with a VA medical examination; yet, the AMC did not procure additional treatment records noted by the Veteran and did not provide the VA examiner with the claims file prior to the writing of the ensuing VA medical examination report, as requested by the Board in the August 2007 Remand. Therefore, the Board remanded the claim again in November 2009 for the procurement of any additional treatment records and another VA medical examination to determine the nature and etiology of the Veteran's claimed heart disorder and disorder manifested by chronic chest pain. Subsequent to the November 2009 Remand, the record indicates that the AMC issued a notice to the Veteran of the time and location for a VA medical examination, but that the AMC did not provide the notice to the Veteran's proper address of record as the Veteran had moved prior to the issuance of the notice. Therefore, in April 2011, the Board remanded the claim again for a VA medical examination. The record indicates that the AMC provided the Veteran with a proper VA medical examination to determine the nature and etiology of the Veteran's heart disorder; however, the Board noted that, in a May 2011 VA medical examination report procured by the AMC, the VA examiner did not properly note private treatment records and evidence of continuity of symptomatology offered by the Veteran in support of his claim for service connection for a disorder manifested by chronic chest pains. In September 2012, the Board again remanded the Veteran's claim for an additional VA examination to determine the nature and etiology of the claimed disorder, and the procurement of any additional treatment records still outstanding. The record indicates that the AMC subsequently obtained all outstanding treatment records, and provided the Veteran with a VA medical examination in February 2013 and, on the recommendation of the February 2013 VA examiner, a VA psychiatric examination in May 2013. After a review of all evidence and proper examinations by both the February 2013 VA medical examiner and the May 2013 VA psychiatric examiner, both VA examiners provided opinions regarding the nature and etiology of the Veteran's claimed disorder associated with chest pain. Therefore, the February 2013 VA medical examination report and the May 2013 VA psychiatric examination report have probative value in this matter. See Prejean v. West, 13 Vet. App. 444, 448 (2000) (indicating that the Board may determine the probative value of medical opinions based on their detail, the persuasiveness of their opinions, and the physicians' access to a veteran's medical records). VA has fulfilled its duty to assist the Veteran by providing proper VCAA notice, procuring the VA treatment records, and providing the Veteran with factually informed and medically supported VA medical and psychiatric examinations. Therefore, the Board finds that the AMC complied with the Board's Remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (noting the Board's duty to "insure [the RO's] compliance" with the terms of its remand orders); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The Veteran has been given ample opportunity to present evidence and argument in support of his claims. The Veteran has not provided VA with sufficient information regarding any additional evidence or authorization and consent forms that would allow for the procurement of any additional evidence not already on file. Therefore, pursuant to 38 C.F.R. § 3.655 (2012), all relevant evidence necessary for an equitable disposition of the Veteran's appeal of these issues has been obtained and the case is ready for appellate review. General due process considerations have been complied with by VA. See 38 C.F.R. § 3.103. Analysis of the Claims Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. 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). Service connection may also be granted for any disease diagnosed after discharge, when all 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 for the claimed disorder, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical, or in certain circumstances, lay evidence of a nexus between the claimed in-service disease or injury and the current disability. See 38 C.F.R. § 3.303; see also Hickson v. West, 12 Vet. App. 247, 253 (1999); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Under 38 C.F.R. § 3.303(b), claims for certain chronic diseases - namely those listed in 38 C.F.R. § 3.309(a) - benefit from a somewhat more relaxed evidentiary standard. See Walker v. Shinseki, 708 F.3d. 1331, 1339 (Fed. Cir. 2013) (holding that "[t]he clear purpose of the regulation is to relax the requirements of § 3.303(a) for establishing service connection for certain chronic diseases."). When a chronic disease is established during active service, then subsequent manifestations of the same chronic disease at any later date, however remote, will be entitled to service connection, unless clearly attributable to causes unrelated to service ("intercurrent causes"). 38 C.F.R. § 3.303(b). In order to establish the existence of a chronic disease in service, the evidence must show a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Id. Thus, the mere manifestation during service of potentially relevant symptoms (such as joint pain or abnormal heart action in claims for arthritis or heart disease, for example) does not establish a chronic disease at that time unless the identity of the disease is established and its chronicity may not be legitimately questioned. Id. If chronicity in service is not established, then a showing of continuity of symptoms after discharge is required to support the claim. Id. The United States Court of Appeals for the Federal Circuit (Federal Circuit) noted that the requirement of showing a continuity of symptomatology after service is a "second route by which a veteran can establish service connection for a chronic disease" under subsection 3.303(b). Walker, 708 F3d. at 1336. Showing a continuity of symptoms after service itself "establishes the link, or nexus" to service and also "confirm[s] the existence of the chronic disease while in service or [during the] presumptive period." Id. (holding that section 3.303(b) provides an "alternative path to satisfaction of the standard three-element test for entitlement to disability compensation"). Significantly, the Federal Circuit indicated that showing a continuity of symptomatology after service is a lesser evidentiary burden than the nexus requirement of the three-part test discussed above: "The primary difference between a chronic disease that qualifies for § 3.303(b) analysis, and one that must be tested under § 3.303(a), is that the latter must satisfy the 'nexus' requirement of the three-element test, whereas the former benefits from presumptive service connection . . . or service connection via continuity of symptomatology" (emphasis added). Id. at 1339. Not all diseases that may be considered "chronic" from a medical standpoint qualify for the relaxed evidentiary standard under section 3.303(b). Rather, the Federal Circuit held that this subsection only applies to the specific chronic diseases listed in 38 C.F.R. § 3.309(a). Id. at 1338-40. Thus, if the claimant does not have one of the chronic diseases enumerated in section 3.309(a), then the more relaxed continuity-of-symptomatology standard does not apply, and "medical nexus of a relationship [sic] between the condition in service and the present condition is required." Id. at 1338; see also id. at 1336, 1340 (holding that the claimant's allegation of a continuity of hearing loss ever since active service was not sufficient to support the claim under subsection 3.303(b), as hearing loss was not among the chronic diseases listed in section 3.309(a)). Because the Veteran is claiming service connection for a cardiovascular disorder, the provisions of subsection 3.303(b) for chronic disabilities apply, and the Veteran's claims for service connection for a heart disorder may be supported by evidence of a continuity of symptomatology after service. Service connection may be granted for the listed chronic diseases, to include cardiovascular disorder, when they are 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 all cases, the Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. Layno v. Brown, 6 Vet. App. 465 (1994). Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); (2) the layperson is reporting a contemporaneous medical diagnosis, or; (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (where widow seeking service connection for cause of death of her husband, the veteran, the Court holding that medical opinion not required to prove nexus between service-connected mental disorder and drowning which caused veteran's death). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-12 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see Madden v. Gober, 125 F.3d 1477, 1481 (Fed Cir. 1997) (holding that the Board has the "authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence"). The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107. A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert, 1 Vet. App. at 49. The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). The Board has considered all evidence of record as it bears on the question of service connection. See 38 U.S.C.A. § 7104(a) (West 2002 & Supp. 2011) ("Decisions of the Board shall be based on the entire record in the proceeding and upon consideration of all evidence and material of record"); 38 U.S.C.A. § 5107(b) ("Secretary shall consider all information and lay and medical evidence of record in a case"). 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. 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 Veteran's appeal. Service Connection for a Heart Disorder The Veteran essentially contends that he developed a heart disorder during service. After a review of the evidence, both lay and medical, the Board finds that the preponderance of the evidence weighs against a grant of service connection for a heart disorder. Specifically, for the entire pendency of the appeal, the Board finds that the Veteran has not had a diagnosed heart disorder for which service connection could be granted. In a June 1977 service treatment record, the Veteran indicated that he had experienced chest pains for the previous two months. After examination, the service examiner noted that the Veteran had a soft systolic murmur and a normal EKG. In a January 1979 service treatment record, the Veteran reported experiencing chest pains. After testing, the service examiner noted that the Veteran's lungs were clear, X-rays were within normal limits, and an EKG showed no significant pathology. In a January 1979 service cardiology report, written the next day, a service examiner noted that the Veteran reported that his heart "beats hard" and that he had difficulty breathing. The Veteran indicated that the symptoms recurred even after being provided pill therapy. The Veteran stated that the condition would last for a minute, and that there was no sensation of carpal or irregular heart action. The service cardiologist wrote that he did not believe that the Veteran's symptoms had a structure of physiological basis and recommended no prescriptions. In a December 1982 service treatment record, the Veteran reported experiencing chest pains for the past month. After an examination, the service examiner diagnosed chest pain and heart murmur. In an additional December 1982 periodic service medical examination report, the service examiner noted finding a faint systolic murmur at the apex and aortic area. In an October 1985 service treatment record, the Veteran reported experiencing a heart murmur and occasional chest pains. Upon examination, the VA examiner noted that the Veteran displayed regular, rate, and rhythm of heart, without murmurs. The service examiner diagnosed chest pain, possibly musculoskeletal. In a December 1985 service discharge examination report, a service examiner noted that the Veteran's heart was normal. In a January 1986 service treatment record, an EKG report indicated that the Veteran had sinus bradycardia. Having reviewed the EKG report, an additional service examiner noted that the Veteran's EKG was within normal limits. Post-service, in an April 1997 private treatment record, the Veteran denied experiencing any exertional chest discomfort. After examination, the private examiner wrote that a screening EKG indicated that the Veteran had sinus bradycardia with a rate of approximately 55. The private examiner also noted mild J-point elevation. The private examiner did not diagnose a heart disorder. In a March 1998 private treatment record, a private examiner noted regular heart rhythm and rate (RRR), with no significant murmurs, gallops, or rub upon examination. In an October 2003 private stress echocardiogram report, a private examiner noted that the Veteran had reduced exercise capacity. The private examiner also noted that the EKG was negative for exercise-induced myocardial ischemia at 93 percent of predicted heart rate. In a June 2008 VA medical examination report, the Veteran reported experiencing chest pains and a heart disorder, specifically sinus bradycardia, since 1977. The Veteran indicated that he was diagnosed as having severe chest pain while stationed in Panama during service. The Veteran reported experiencing continual or intermittent chest pain since that time. The Veteran stated that the pain increased in frequency during periods of increased stress or physical exertion. The Veteran indicated that he currently worked as a postal worker and reported experiencing pain at various times during the day, causing him to have to stop work until the pain went way, usually within 30 to 60 seconds. The Veteran denied experiencing any heart trauma, cardiac neoplasm, myocardial infarction, congestive heart disease, rheumatic heart disease, hypertensive heart disease, syphilitic heart disease, endocarditis, pericarditis, syncope, fatigue or dizziness. The Veteran indicated that he experienced angina on a daily basis and dyspnea upon severe exertion. The Veteran stated that he had experienced chest pain that morning, but denied experiencing any upon examination. Upon reviewing a contemporaneous chest X-ray report, the VA examiner noted that the Veteran's heart appeared normal. The VA examiner also indicated that an echocardiogram indicated trace mitral regurgitation and trace pulmonic regurgitation. Having reviewed the evidence of record, the VA examiner indicated that the trace mitral regurgitation and trace pulmonic regurgitation were less likely than not caused by or related to the Veteran's service. The VA examiner noted that the Veteran had been diagnosed with a heart murmur during service and that this disorder had continued to have a minimal impact on the health of the Veteran. The VA examiner, having written the final draft of the examination report in late July 2008, noted that the Veteran did not appear for a scheduled stress test in early July 2008 that, according to the examiner, could have determined whether the Veteran had any current heart disorder that impacted his quality of life and activities of daily living during periods of stress. In a July 2008 VA treatment record, specifically an electronic cardiac stress test report, a VA examiner noted that the Veteran was exercised a total of nine minutes and 56 seconds according to test parameters, prior to developing shortness of breath and dizziness, without chest pain. The VA examiner noted that the Veteran's peak heart rate achieved was 150 beats per minute, representing 88 percent of the submaximum age-predicted heart rate. The VA examiner noted that the test was negative for ischemic sinus tachycardia change. The VA examiner noted that, following the stress test, the Veteran developed chest pain measuring four on a scale of 10 in intensity. The VA examiner indicated that an EKG done at that time was normal and that the Veteran's pain subsided promptly. The VA examiner reported that the Veteran waited 15 to 20 minutes without recurrences and was released. The Veteran opined that the Veteran's chest pain was not cardiac in etiology. In a May 2011 VA medical examination report, the Veteran reported experiencing chest pains in his lower left chest since 1977. The Veteran indicated that the pain could be exacerbated either by anxiety or movement. The Veteran denied experiencing heart rhythm disturbance, valvular heart disease including prosthetic valve, myocardial infarction, congestive heart disease, other heart disease, angina, syncope, fatigue or dizziness. The Veteran reported experiencing dyspnea at rest. The Veteran indicated that he would get shortness of breath during chest pain episodes, either at rest or with exertion. Upon examination, the VA examiner noted no signs of congestive heart failure or pulmonary hypertension. The VA examiner indicated that heart sounds were present and that there were no extra heart sounds. The VA examiner specially noted finding that the Veteran did not have a heart murmur. The VA examiner indicated that the Veteran's 2008 echocardiogram, indicating the presence of trace mitral regurgitation and trace pulmonic regurgitation, was essentially normal, showing no signs of a heart disorder. The VA examiner also noted that the Veteran had a normal EKG in July 2008, and that a July 2008 stress test was normal. Having reviewed the evidence, both lay and medical, interviewed the Veteran, and conducted a thorough examination, the VA examiner stated that the Veteran did not have a current heart disability. The VA examiner noted that the Veteran's symptoms were inconsistent with a disorder of a cardiac etiology and the Veteran had undergone multiple EKGs, echocardiograms, and stress tests that had ruled out a heart problem. The VA examiner noted that in-service tests detected a heart murmur, but that this was not present during that day's examination. The VA examiner further noted that diagnosed bradycardia was a sign of health expected in young soldiers. The Veteran has not experienced a heart disorder during the pendency of the appeal, dating back to the filing of the Veteran's claim to reopen service connection for a heart disorder in February 2003. Specifically, treatment records for that period indicate that multiple examiners have not the diagnosed the Veteran as having any heart disorder. In the June 2008 VA medical examination report, a VA examiner noted that an echocardiogram found trace mitral regurgitation and trace pulmonic regurgitation. However, neither the June 2008 VA examiner or the subsequent May 2011 VA examiner, having reviewed the June 2008 echocardiogram, specifically found that these were heart disorders in themselves or indications of a heart disorder. Specifically, in the June 2008 VA medical examination report, having found that the Veteran had trace mitral regurgitation and trace pulmonic regurgitation, the June 2008 VA examiner indicated that a stress test would be required to determine if the Veteran had a heart disorder. Moreover, the May 2011 VA examiner, in reviewing the findings of trace mitral regurgitation and trace pulmonic regurgitation, indicated that they were not a disorder in and of themselves, and that the June 2008 echocardiogram was essentially normal. The remainder of the cardiac testing provided during the pendency of the appeal contains no other findings suggesting any heart abnormality. As the evidence indicates that the Veteran does not currently have a heart disorder and has not had such a disorder during the pendency of the appeal, service connection for this disorder is precluded. See e.g., Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (finding that in the absence of proof of present disability there can be no valid claim. Service Connection for Chest Pains The Veteran essentially contends that he developed a disorder manifested by chronic chest pain during service in Panama. After a review of the evidence, both lay and medical, the Board finds that the preponderance of the evidence weighs against a grant of service connection for chest pain. Chest pain alone is not a disability for which service connection may be granted. Therefore, for a grant of service connection, the evidence must indicate the presence of a diagnosed disorder related to service causing chest pains. See Sanchez-Benitez v. West, 13 Vet. App. 282 (1999), appeal dismissed in part, and vacated and remanded in part sub nom. Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001) (holding that pain alone, without a diagnosed or identifiable underlying malady or condition, is not a disability). In a November 1977 service treatment record, the Veteran reported experiencing non-radiating pericardial chest pain, usually at rest, increasing for the previous few weeks. The Veteran reported that the pain was not related to exertion. After an examination, the service examiner diagnosed chest pains of the upper extremity, doubt cardial etiology. In a December 1977 service treatment record, the Veteran reported that he had experienced sharp chest pain over the previous two months. The Veteran indicated that the pain would last only about two seconds. In an additional record, the Veteran stated that he experienced two types of pain, a sharp pain and a "bubble pain" that moved from side to side. In a subsequent December 1977 service treatment record, the Veteran reported that his chest pains were lessening. The service examiner wrote that an examination was within normal limits. In a January 1979 service treatment record, the Veteran reported experiencing chest pains. After testing, the service examiner noted that the Veteran's lungs were clear, X-rays were within normal limits, and EKG showed no significant pathology. In a January 1979 service cardiology report, written the next day, a service examiner noted that the Veteran reported that his heart "beats hard" and that he had difficulty breathing. The Veteran indicated that the symptoms recurred even after being provided pill therapy. The Veteran stated that the condition would last for a minute, and that there was no sensation of carpal or irregular heart action. The service cardiologist wrote that he did not believe that the Veteran's symptoms had a structural or physiological basis and recommended no prescriptions. In a January 1979 service treatment record, written the same day, the service examiner noted the cardiologist's findings. The service examiner diagnosed intercostal myalgia. In a February 1979 service treatment record, the Veteran reported experiencing chest pains and heart pains. The service examiner assessed left chest pain with a history of intercostal myalgia versus costochondritis at the left fourth costochondral junction. In a February 1979 service treatment record, written the same day, a service examiner reported that the Veteran had been referred by the aid station for injection treatment due to complaints of chest pain. The service examiner noted giving the Veteran an injection of xylocaine and lidocaine. The service examiner diagnosed intercostal myalgia. In a December 1982 service treatment record, the Veteran reported experiencing chest pains for the past month. After an examination, the service examiner diagnosed chest pain and heart murmur. In a December 1982 periodic service medical examination report, the service examiner noted finding a faint systolic murmur at the apex and aortic area. In an October 1985 service treatment record, the Veteran reported experiencing a heart murmur and occasional chest pains. Upon examination, the VA examiner noted that the Veteran displayed regular, rate, and rhythm of heart, without murmurs. The service examiner diagnosed chest pain, possibly musculoskeletal. In a December 1985 service discharge examination report, a service examiner did not note any abnormality related to chest pains. Post-service, in a November 1997 private treatment record, the Veteran reported experiencing a two-day history of head and nasal congestion with nasal stuffiness. The Veteran also indicated that he was experiencing a cough with some shortness of breath and chest discomfort on coughing. After an examination, the private examiner diagnosed bronchitis, reactive airway disease with bronchospasm, and rhinitis. In an additional November 1997 private treatment record, the Veteran reported experiencing mild chest discomfort. After an examination, the private examiner diagnosed, bronchospasm resolved, bronchitis, and rhinitis. In a February 1998 private treatment record, the private examiner, after listening to the Veteran report of his symptomatology and performing an examination, diagnosed probable chest wall muscle pain described. In an April 2003 statement, the Veteran wrote that he had experienced chest pains for so long that he was used to it. The Veteran indicated that the pain in his chest was "very scary" and might last for a few minutes to all day. The Veteran stated that he could not continue to go to the doctor for treatment of his chest pains due to his job. The Veteran wrote that he had other claims that he could submit, such as back pain and allergies, but that he was more interested in his claim for chest pains. The Veteran stated that he knew that he would live with his chest pains for the rest of his life. In a November 2004 statement, the Veteran wrote that he had experienced chest pain daily since his 1986 discharge from service and indicated that such pain was scary. In a January 2005 private chest X-ray report, a private examiner noted that the Veteran's chest was normal. In a March 2005 private chest CT scan report, a private examiner noted that the Veteran's chest was normal. In a March 2008 private treatment record, specifically a wellness check, the Veteran denied experiencing chest pain. As noted above, in a June 2008 VA medical examination report, the Veteran reported experiencing chest pain to the VA examiner. The Veteran indicated that he was diagnosed as having severe chest pain while stationed in Panama during service. The Veteran stated that he was provided with an injection in his chest near the heart during service in 1978. Although the service examiners provided the injection to treat the chest pains, the Veteran recalled experiencing pain during the treatment. The Veteran reported experiencing continual or intermittent chest pain since that time. The Veteran stated that the pain increased in frequency during periods of increased stress or physical exertion. The Veteran indicated that he currently worked as a postal worker and reported experiencing pain at various times during the day, causing him to have to stop work until the pain went way, usually within 30 to 60 seconds. The VA examiner did not report finding any source of the chest pains. In a subsequent July 2008 VA treatment record, having provided heart tests followed by chest pains, a VA examiner opined that the Veteran's chest pain was not cardiac in etiology. In a February 2011 private treatment record, the Veteran reported experiencing 30 years of anterior left-sided chest wall pain, lasting about 10 seconds twice a day, about five times per week. The Veteran stated that it had been going on since he was stationed in Panama in 1977. The Veteran indicated that he had not experienced any trauma to the chest area that he could recall. The Veteran stated that he had been employed as a letter carrier and indicated that, at times, he had to stop performing his duties due to these episodes. The Veteran also reported that the episodes would always resolve completely and he would return to a baseline without any symptomatology. The Veteran indicated that the pain was sharp and stabbing, and that he thought that it might be stress-induced. After an examination, the private examiner opined that the Veteran had a 30-year history of anterior chest wall pain which appeared to be more rib dysfunction and costochondritis, that always completely resolved. In a February 2011 statement, the Veteran wrote that the February 2011 private treatment record confirmed that he had a rib injury just underneath his chest area that irritated his nerves and muscles. In the May 2011 VA medical examination report, the Veteran reported experiencing sharp chest pains in the lower left chest, beginning in 1977, lasting up to 10 minutes per occurrence. The Veteran indicated that he continued to experience this pain daily. The Veteran indicated that the pain could be exacerbated either by anxiety or movement. The Veteran stated that he had been to a specialist who had elicited symptoms by pressing on his chest wall. The specialist reportedly told the Veteran that he was experiencing costochondritis. The Veteran stated that he would experience shortness of breath with each painful episode, occurring either with rest or exertion. After an examination, the VA examiner diagnosed atypical chest pain. The VA examiner noted that the Veteran exhibited some features suggestive of costochondritis, but that the atypical factors claimed by the Veteran to precipitate symptoms over the alleged 30-year course disorder were not consistent with that diagnosis. The VA examiner noted that the diagnosis of rib dysfunction and costochondritis were diagnoses of exclusion, based on both the lack of another clear cause, cardiac or otherwise, and the noted pain upon palpation. The VA examiner wrote that one would not expect a local inflammatory condition such as costochondritis to persist for over 30 years or to be exacerbated by stress. The VA examiner noted that the Veteran's reported symptoms began during service, but that he saw nothing to suggest that the pains were etiologically related to it. The VA examiner indicated that the Veteran worked full-time at a physically demanding occupation without any significant disability. In a June 2012 statement, the Veteran wrote that his chest pains first began while he experienced the stress of serving in Panama, immediately preceding the conflict in that area, to include the stress caused by the need for constant readiness and fear of attack. The Veteran stated that, recently, a doctor told him that his gripping chest pains were due to anxiety attacks and corresponding muscle spasms. In a November 2012 private treatment record, a private examiner diagnosed chest wall pain. In a February 2013 VA medical examination report, a VA examiner noted that, during service, the Veteran served in an administrative position including supply, transportation, and testing of materials and chemicals. The VA examiner indicated that the supply position and testing positions required repetitive heavy lifting, and, sometimes, the carrying of equipment into test sites in the jungles of Panama. The Veteran reported that, on being stationed in Panama, he experienced gradual onset of increasingly intense chest pain centered at the left sternal border that worsened as the day went on. The Veteran indicated that antacids had no effect on the pain. The Veteran indicated that, on days of pain, he would suddenly wake up with symptoms of trouble breathing, fear, anxiety, chest pain, difficulty sleeping, and feelings of edginess. The Veteran indicated that he had difficulties with his supervisor during service. The Veteran reported experiencing worsening pain when delivering mail in 1998. The Veteran stated that he had been diagnosed with costochondritis or rib dysfunction. The Veteran indicted that he had been divorced three times and that he and his current wife were estranged. However, after an examination, a review of the claims file, and an interview with the Veteran, the VA examiner diagnosed the Veteran as not having any muscle disorder or any other physical disorder causing chest pains. The VA examiner wrote that the Veteran was tentatively diagnosed with costochondritis while on active duty. The VA examiner indicated that this condition, if present, should have responded to injection therapy during service in 1979. The record, both lay and medical, indicated that the condition had not responded. The VA examiner noted that this effectively ruled out an inflammatory condition, such as costochondritis. The VA examiner further noted that costochondritis affected young women primarily, was usually self-limiting, and would not exist chronically for over 30 years as the Veteran was claiming. The VA examiner indicated that the Veteran was giving descriptions of events which sounded more akin to panic attacks and, even during the examination, the Veteran was able to recall the fear of being in Panama where he felt discriminated against and alone. The VA examiner wrote that palpations and fear did not accompany costochondritis or a primary inflammatory disorder. The VA examiner found that the costochondritis diagnosed within the past few years, if in existence, seemed to be more likely as not diagnosed as related to overuse such as heavy lifting and carrying, as required of a postal worker. The VA examiner wrote that, in summary, the clinical picture did not support chronic costochondritis over the previous 30 years, beginning in service. Instead, the VA examiner noted that the Veteran's symptomatology, noted in the service treatment records, were more reminiscent of an anxiety disorder with somaticism. The Veteran also underwent a VA psychiatric examination in May 2013. While very detailed in its description of the Veteran's pre-service, service, and post-service history, it suffices to note that the VA examiner observed that, while the Veteran did not have a history of behavioral difficulties, he described a longstanding pattern of interpersonal difficulties and problems relating to others. The VA examiner wrote that the Veteran appeared normal and was in high spirits at the beginning of the interview. The Veteran's cognitive skills, orientation, recall, memory functioning, abstract thinking, and general fund of information were all found to be normal. The VA examiner noted that the Veteran was unable to fully explain the meaning of three proverbs, potentially reflecting a tendency toward more concrete reasoning abilities. Significantly as it bears on the Veteran's credibility, the VA examiner reported finding that the Veteran endorsed a number of symptoms on clinical interview that were inconsistent with behavioral observations, occupational history, and available treatment records. As an example, the VA examiner noted that the Veteran endorsed experiencing audio-visual hallucinations during the interview, reporting that he heard male voices in the form of "chatter," occurring from time to time, occasionally telling him to kill himself. The VA examiner also indicated that the Veteran reported seeing "shadows walk across" his field of vision. However, the VA examiner wrote that the Veteran was vague as to when he first saw these "shadows," but that the Veteran indicated that he believed he first saw them during service. The VA examiner wrote that there was no evidence upon interview that the Veteran was distracted by or responding to internal stimuli, and that the Veteran had never reported or established treatment history for such experiences. The VA examiner reported that the Veteran did not appear distressed when discussing these experiences, even when describing how the voices told him to kill himself. Given the inconsistency between the Veteran's report of psychotic symptomatology, his apparent level of occupational functioning, and his lack of significant mental health treatment history, the VA examiner found that a more formal assessment of symptom validity was required and initiated the assessment. The VA examiner noted that, on one such test, made to screen for symptom dissimulation or exaggeration, the Veteran received a raw score of 16, exceeding the recommended cut-point indicative of suggested symptoms dissimulation. On a self-report inventory, assessing exaggerated negative symptom presentation, the Veteran's score was significantly elevated above both the recommended cutoff score for the identification of suspected symptom dissimulation as suggested by the interpretive guidelines developed for the test and the recommend cutoff score proposed by the VA Mid-Atlantic Health Care Network (VISN-6) Task Force for determining invalid symptom presentation. The VA examiner noted that the Veteran endorsed a high frequency of symptoms that were highly atypical of patients with genuine psychiatric or cognitive disorders. The VA examiner observed that a psychiatric condition that would explain the Veteran's symptomatology in question (i.e. chest pain-related anxiety or panic symptoms) could not be ruled out. However, given that the Veteran's scores were above established cutoff points on two validated screening measures for symptom dissimulation and that there existed an incongruence between the Veteran's subjective report of symptomatology and the objective data (i.e., behavioral observations, work history, and available medical record), the VA examiner found that there was insufficient evidence to substantiate any mental disorder diagnosis without resorting to undue speculation regarding the true nature of the Veteran's current psychological functioning. The preponderance of both the physiological and psychological evidence is against the claim of service connection for a disorder manifested by chronic chest pain. Specifically, the Board finds that the Veteran does not have a current disorder manifested by chronic chest pain that began during service or is related to any incident of service. The Veteran reported experiencing chest pains on an intermittent basis during service, and was diagnosed by service examiners as having various non-heart related disorders, such as intercostal myalgia versus costochondritis. Yet, the Veteran's service discharge examination report contains no notation indicating any present abnormality resulting in chest pains at the time of discharge. The first post-service treatment record indicating treatment or diagnosis for non-cold disorder-related chest pains is dated 1998, more than a decade after the Veteran's service discharge. Although the Veteran contended that he experienced chest pains since his discharge from service, the Veteran has been inconsistent in his description of the pains themselves and the continuity of his symptomatology. For example, in an April 2003 statement, the Veteran reported that he experienced chest pains which could last from a few minutes to the entire day. Yet, in other records, the Veteran reported that the pains lasted for only minutes or, in some instances, seconds. Also, in the June 2008 VA treatment record, the Veteran stated that he had experienced both "continual" and "intermittent" chest pain since 1977. Considering the Veteran's lack of consistency regarding the Veteran's statements of his chest pain symptomatology and the continuity of such symptomatology since service, the Board finds that they are of lessened credibility in this matter. See Caluza, 7 Vet. App. at 511-12. The Veteran claims that private treatment records contain diagnoses proving that he has physical disorders, specifically rib dysfunction and costochondritis, which began during service. In support of this contention, the Veteran noted that, in a February 2011 private treatment record, a private examiner opined that the Veteran had a 30-year history of anterior chest wall pain, which appeared to be more rib dysfunction and costochondritis, that always completely resolved. Yet, the Board notes that the February 2011 private examiner, seemingly, made his opinion based entirely on the Veteran's reported history which, as noted above, is of lessened credibility in this matter. See id. Reviewing the VA examination reports, in the May 2011 VA medical examination report, a VA examiner noted reviewing the medical evidence in the claims file. Having performed an examination and interviewed the Veteran, the May 2011 VA examiner diagnosed atypical chest pain. The VA examiner noted that there were some features suggestive of costochondritis, but that the atypical factors claimed by the Veteran to precipitate symptoms over the alleged 30-year course of the disorder were not consistent with that diagnosis. The VA examiner noted that the diagnosis of rib dysfunction and costochondritis were diagnoses of exclusion, based on the lack of a cardiac-related cause or other clear causes, and the noted pain upon palpation. The VA examiner wrote that one would not expect a local inflammatory condition such as costochondritis to persist for over 30 years or to be exacerbated by stress. The VA examiner noted that the Veteran's reported symptoms began during service, but that he saw nothing to suggest that the pains were etiologically related to it. Likewise, in the February 2013 VA medical examination report, the VA examiner noted reviewing the evidence, specifically noting many of the in-service instances when the Veteran reported experiencing chest pain in the report. Having interviewed the Veteran and provided an examination, the VA examiner diagnosed the Veteran as having no physical disorder manifested by chronic chest pain. In explaining this conclusion, the VA examiner noted that the Veteran had been diagnosed recently as having costochondritis and that the Veteran was tentatively diagnosed with costochondritis while on active duty. The VA examiner indicated that this condition, if present during service, should have responded to injection therapy during service in 1979; yet, the record, both lay and medical, indicated that the condition had not responded to this therapy as the Veteran continued to report feeling chest pains after the injection. The VA examiner noted that this effectively ruled out an in-service inflammatory condition, such as costochondritis. The VA examiner further noted that costochondritis affected young women primarily, was usually self-limiting, and would not exist chronically for over 30 years as the Veteran was claiming. The VA examiner indicated that, during an interview, the Veteran gave descriptions of events which sounded more akin to panic attacks. The VA examiner wrote that palpations and fear did not accompany costochondritis or a primary inflammatory disorder. The VA examiner found that the costochondritis diagnosed within the past few years, if in existence, seemed to be more likely as not diagnosed as related to overuse such as heavy lifting and carrying, as required of a postal worker. The VA examiner wrote that, in summary, the clinical picture did not support a diagnosis of chronic costochondritis over the previous 30 years, beginning in service. Instead, the VA examiner noted that the Veteran's symptomatology, noted in the service treatment records, was more reminiscent of that associated with an anxiety disorder with somaticism. As noted above, the VA examiner indicated that the Veteran's in-service symptomatology were reminiscent of an anxiety disorder, but did not either diagnose the Veteran as having an in-service anxiety disorder based on the evidence or diagnose the Veteran as having a current anxiety disorder. In the May 2013 VA psychiatric examination report, a VA examiner noted reviewing the claims file, performing an interview, and performing an extensive mental evaluation, including specialized testing to determine the validity of the Veteran's reported symptoms. Having done so, given that the Veteran's scores were above established cutoff points on two validated screening measures for symptom dissimulation and that there existed an incongruence between the Veteran's subjective report of symptomatology and the objective data (i.e., behavioral observations, work history, and available medical record), the VA examiner found that there was insufficient evidence to substantiate any mental disorder diagnosis with resorting to undue speculation regarding the true nature of the Veteran's current psychological functioning. As noted above, the May 2011 VA and February 2013 VA medical examiners, and the May 2013 VA psychiatric examiner provided opinions regarding the nature and etiology of the Veteran's claimed disorder associated with chest pain based on examinations and interviews of the Veteran, with references to evidence in the claims file. Therefore, the Board finds that the May 2011 and February 2013 VA medical examination reports, and the May 2013 VA psychiatric examination report have great probative value in this matter. See Prejean, 13 Vet. App. at 448. Based on this evidence, the Board finds that the Veteran does not have either a physical or a psychiatric disorder manifested by chronic chest pain related to service. Therefore the preponderance of the evidence is against the Veteran's claim for service connection for a disorder manifested by chronic chest pain, and it must be denied. 38 U.S.C.A. § 5107(b); Alemany v. Brown, 9 Vet. App. 518 (1996). ORDER Service connection for a heart disorder is denied. Service connection for a disorder manifested by chronic chest pain is denied. ____________________________________________ VITO A. CLEMENTI Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs