Citation Nr: 1329648 Decision Date: 09/16/13 Archive Date: 09/20/13 DOCKET NO. 07-16 192 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUE Entitlement to service connection for cardiac arrhythmia, claimed as secondary to PTSD. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. Davitian, Counsel INTRODUCTION The Veteran served on active duty from May 1967 to January 1969. This matter comes before the Board of Veterans' Appeals (BVA or Board) on appeal from an August 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee, that denied service connection for premature atrial tachycardia, pacemaker and mitral valve prolapse (claimed as heart). In May 2008, a local hearing was held with a Decision Review Officer and, in May 2010, a Central Office hearing was held before the undersigned. Transcripts of these hearings are associated with the claims file. The Board remanded this matter in February 2011 and August 2012. The August 2012 remand observed that during the pendency of the appeal a March 2012 rating decision (in the electronic record) had denied service connection for ischemic heart disease as a presumptive disease under Nehmer v. United States Department of Veterans Affairs, 712 F. Supp. 1404, 1409 (N.D. Cal. 1989). Service connection was denied because there was no evidence of a current diagnosis of ischemic heart disease. The Veteran did not file a notice of disagreement with that decision. The August 2012 remand also found that the Veteran's claim for secondary service connection for heart disease was still on appeal since he had other diagnosed heart conditions, to include premature atrial tachycardia, pacemaker, and mitral valve prolapse. The case is now before the Board for final appellate consideration. FINDING OF FACT The competent clinical evidence and competent and credible lay evidence demonstrates that it is at least as likely as not that the Veteran's cardiac arrhythmia is due to, the result of, or chronically aggravated by, service-connected disability. CONCLUSION OF LAW Cardiac arrhythmia is proximately due to, the result of, or chronically aggravated by, service-connected disability. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. § 3.310(a) (2012). REASONS AND BASES FOR FINDING AND CONCLUSION VA has a 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. 2009); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). In this case, the Board is granting the Veteran's secondary service connection claim. Accordingly, assuming, without deciding, that any error was committed with respect to either the duty to notify or the duty to assist, such error was harmless and will not be further discussed. A veteran is entitled to secondary service connection for a disability which is proximately due to, the result of, or aggravated by an established service-connected disorder. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). Secondary service connection includes instances in which an established service-connected disorder results in additional disability of another condition by means of aggravation. Allen, supra. In each case where a veteran is seeking service connection for any disability, 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). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. 38 U.S.C.A. § 5107(b). The Veteran contends that he his service-connected PTSD results in cardiac arrhythmia. A May 2013 rating decision granted the Veteran's claim for service connection for PTSD. The evaluation is 70 percent. Based on a thorough review of the record, the Board finds that the evidence is in equipoise as to whether the Veteran's cardiac arrhythmia is proximately due to, the result of, or aggravated by his service-connected PTSD. The Board's August 2012 remand recognized that the Veteran has diagnosed heart conditions that include premature atrial tachycardia. In addition, an August 2004 letter from a private physician observes that the Veteran had recently had nonsustained and sustained atrial tachycardia. A July 2005 private hospital discharge summary provides that the discharge diagnosis was paroxysmal atrial fibrillation. A June 2012 VA cardiology consult report relates that the Veteran had been followed by a private cardiologist for atrial fib. The pertinent assessment was palpitations and history of atrial fib. A June 2012 private discharge summary provides pertinent discharge diagnoses of paroxysmal atrial fibrillation; tachybrady syndrome, pacemaker in placed (sic); and atrial fibrillation. The Veteran contends that his observable symptoms of cardiac arrhythmia began with the development of his service- connected PTSD and have continued to the present. See June 2004 report of private treatment from M. J. D-A., M.D. The Veteran is competent to so testify. See Falzone v. Brown, 8 Vet. App. 398, 405 (1995). The Board finds him to be credible in this regard. Lay testimony is competent to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994). Additionally, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether that evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Further, lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (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). Thus, in this case, the Board finds that the Veteran's testimony is competent and credible lay evidence that his current cardiac arrhythmia began with the development of his service-connected PTSD. The Board is aware that a May 2013 VA medical opinion stated that the Veteran's current heart condition, including mild mitral valve prolapse, mild mitral regurgitation, mild left ventricular enlargement, mild left atrial enlargement, history of sick sinus syndrome (SSS), history of atrial fibrillation and a pacemaker implant for SSS, were less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service- connected PTSD. The examiner explained that there was no scientifically based medical literature to provide evidence of a causal or risk factor relationship between PTSD and the Veteran's currently diagnosed heart conditions. The examiner referred to, summarized, and provided excerpts from two medical texts. The examiner summarized that the first text noted that while anxiety disorders could include symptoms of rapid heartbeat, the anxiety disorder did not cause physical changes, i.e., chamber enlargement, valve prolapse and regurgitation, or SSS. The examiner summarized that the second text linked the Veteran's mitral valve prolapse and regurgitation to the rest of his echocardiogram findings and arrhythmias, including premature atrial tachycardia, that he had experienced. The examiner stated that the Veteran's family history of mitral valve prolapse suggested a possible genetic basis. PTSD was not the cause. The Board finds that, according to the examiner's own summary, the first text supports the Veteran's claim insofar as it notes that anxiety disorders could include symptoms of rapid heartbeat. The June 2004 report of private treatment from Dr. M. J. D- A. provides that the Veteran's guilt over events in Vietnam had been contributing to the palpitations, etc., that the Veteran had had. A May 2010 letter from Dr. M. J. D-A. relates that he had treated the Veteran since March 1999. He stated that the Veteran had a history of chronic anxiety and cardiac palpitations that he (Dr. M. J. D-A.) thought were related. A June 2013 medical opinion from a private cardiologist provided that the Veteran's arrhythmias were much more likely to be related to the Veteran's PTSD than to his very mild mitral valve prolapse. The private cardiologist reviewed the Veteran's pertinent medical evidence in detail, including VA medical records. He noted that arrhythmias were not necessarily associated with mitral valve prolapse. In support, he cited and summarized several studies. The private cardiologist also noted that most of the Veteran's symptoms occurred when he was anxious, having nightmares or under stress. He cited and summarized several studies that showed physiological and chemical changes in patients with PTSD or who had prolonged stress exposure, as compared to healthy controls. These changes included higher 24-hour urinary norepinephrine levels and a sensitized cardiovascular response to alpha 2 receptor antagonists. In addition, clonidine had been used to treatment symptoms of PTSD successfully. The Board finds that the May 2013 VA medical opinion and June 2013 private medical opinion are each probative. Both are based on a review of the medical record, and both analyze the Veteran's post-service medical history in terms of medical principles, medical articles and medical studies. This fact is particularly important, in the Board's judgment, as the references make for more convincing rationales. See Bloom v. West, 12 Vet. App. 185, 187 (1999) (the probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion"). See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion.); Elkins v. Brown, 5 Vet. App. 474, 478 (1993) (medical opinions as to a nexus may decline in probative value where the physician fails to discuss relevant medical history). In light of the foregoing, the Board finds that the competent clinical evidence of record is in equipoise as to whether the Veteran's cardiac arrhythmia is related to his service-connected PTSD. In this regard, the Board notes that in Alemany v. Brown, 9 Vet. App. 518 (1996), the Court of Appeals for Veterans Claims stated that in light of the benefit of the doubt provisions of 38 U.S.C.A. § 5107(b), an accurate determination of etiology is not a condition precedent to granting service connection; nor is "definite etiology" or "obvious etiology." Further, in Gilbert v. Derwinski, 1 Vet. App. 49 (1990), the Court stated that a veteran need only demonstrate that there is an approximate balance of positive and negative evidence in order to prevail. The Court specifically stated that entitlement need not be established beyond a reasonable doubt, by clear and convincing evidence, or by a fair preponderance of the evidence. Under the benefit of the doubt doctrine established by Congress, when the evidence is in relative equipoise, the law dictates that the appellant prevails. See also 38 C.F.R. § 3.102. With resolution of doubt in the Veteran's favor, the Board finds that the evidence of record is sufficient to establish service connection for cardiac arrhythmia, secondary to service-connected PTSD. See Gilbert, supra. ORDER Service connection for cardiac arrhythmia, secondary to service-connected PTSD, is granted. ____________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs