Citation Nr: 1336207 Decision Date: 11/06/13 Archive Date: 11/13/13 DOCKET NO. 09-49 032 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUE Entitlement to service connection for a cardiovascular disorder, to include as secondary to the service-connected symptomatic sinus bradycardia, status post pacemaker insertion. REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD J. Chapman, Associate Counsel INTRODUCTION The appellant had active service from November 1987 to November 1992. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. A July 2013 Board decision reopened this claim and remanded the matter for additional development. This appeal was processed using the Virtual VA paperless claims processing system. Accordingly, any future consideration of this appellant's case should take into consideration the existence of this electronic record. FINDING OF FACT A cardiovascular disorder was not present during service and is not otherwise causally related to service, to include caused or aggravated by any service-connected disability. CONCLUSION OF LAW A cardiovascular disorder was not incurred or aggravated in service, and was not proximately due to or the result of a service-connected disability. 38 U.S.C.A. §§ 1101, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION VA's Duties to Notify and Assist The 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; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 & 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The Veteran was notified in a letter dated in October 2007 regarding the type of evidence necessary to establish his claim. He was instructed how to establish service connection. The Veteran was notified of what evidence and/or information was already in the RO's possession, what additional evidence and/or information was needed from the Veteran, what evidence VA was responsible for getting, and what information VA would assist in obtaining on the Veteran's behalf. This letter also notified the Veteran of the criteria for assigning a disability rating and an effective date. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Regarding VA's duty to assist, VA obtained the Veteran's service treatment records (STRs) and post-service medical records. VA examinations, as related to the matter on appeal, were obtained in June 2012 and September 2013. 38 C.F.R. § 3.159(c)(4). Taken together, the VA examinations obtained in this case are sufficient, as the examiners conducted complete examinations, recorded all findings considered relevant under the applicable law and regulations, and the September 2013 examiner offered a well-supported opinion based on consideration of the full history of the disorder. The Board finds that VA's duty to assist the Veteran with respect to obtaining a VA examination concerning the issue adjudicated herein has been met. 38 C.F.R. § 3.159(c)(4). VA has no duty to inform or assist that was unmet. The Veteran has not identified any additional pertinent medical records that have not been obtained and associated with the claims folder. In reaching this conclusion, the case was remanded in July 2013, in part, to obtain additional private treatment records. The AMC sent the Veteran an Authorization and Consent to Release Information form in order to obtain additional records. However, the Veteran failed to return that form; consequently, additional private records were not obtained. See Wood v. Derwinski, 1 Vet. App. 190 (1991) (the duty to assist is not a one-way street). Legal Criteria, Factual Background, and Analysis Service connection may be granted for disability resulting from disease or injury incurred or aggravated during active military service. 38 U.S.C.A. § 1131. Generally, service connection requires (1) the existence of a present disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Lay assertions may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Additionally, service connection may be granted, on a secondary basis, for a disability which is proximately due to or the result of an established service-connected disorder. 38 C.F.R. § 3.310. Similarly, any increase in severity of a non-service-connected disease or injury that is proximately due to or the result of a service-connected disease or injury will be service-connected. Allen v. Brown, 7 Vet. App. 439 (1995). In the latter instance, the non-service-connected disease or injury is said to have been aggravated by the service-connected disease or injury. 38 C.F.R. § 3.310. In cases of aggravation of a Veteran's non-service-connected disability by a service-connected disability, the Veteran shall be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.322. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Initially, the Board notes that it has reviewed all the evidence in the Veteran's claims file and in Virtual VA. Although the Board has an obligation to provide adequate reasons and bases supporting its decision, there is no requirement that the Board discuss every piece of evidence in the record. Rather, the Board will summarize the relevant evidence, as appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claim. See Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). The Veteran contends that he developed a cardiovascular disorder as due to service. See August 2007 statement. The Board has conducted a careful review of the record, and concludes that the record is without sufficient evidence supportive of a finding that the Veteran's current cardiovascular disorder became manifest or otherwise originated during his period of service, or is otherwise related to his military service, to include as due to a service-connected disability. There is no finding that any chronic cardiovascular disorder was treated or diagnosed during service. The Veteran's September 1987 entrance examination and separation examination dated in 1992 revealed his heart was normal on clinical evaluation. Although STRs revealed numerous complaints of chest pain and show that the Veteran was profiled for atypical chest pain, and show diagnoses of angina and chest pain, rule out myocardial infarction in September 2009, these records show this chest pain was continually assessed as non-cardiac chest pain/not of cardiac origin. Notably, in May 1991, an electrocardiogram was negative for ischemia and the Veteran had an excellent exercise tolerance test. In March 1992, it was indicated that in light of the multiple normal studies (including an electrocardiogram), the chest pain is "about certainly not cardiogenic." Accordingly, although his STRs clearly reflect complaints of chest pain, there is no indication that a chronic heart/cardiovascular disorder resulted from service. The Veteran's contemporaneous service records fail to show that the onset of any cardiovascular disorder occurred during service. The totality of the evidence fails to show that the onset of any cardiovascular disorder occurred during the Veteran's service. No medical professional has reported that the onset of a cardiovascular disorder (other than the already service-connected bradycardia) began during the Veteran's military service. What remains for consideration is whether or not a cardiovascular disorder may somehow otherwise be related to the Veteran's service. The pertinent medical evidence that has been presented shows a current diagnosis of hypertensive heart disease/left ventricular hypertrophy; however, the evidence does not contain a medical opinion relating any currently diagnosed cardiovascular disorder to the Veteran's military service, to include being secondary to his service-connected bradycardia. VA treatment records show that in June 2002, the assessment was coronary artery disease. In May 2007, the Veteran reported having four left heart catheterization procedures which all revealed normal coronary arteries. In August 2007, no active cardiopulmonary disease and no congestive heart failure were noted. In March 2008, questionable coronary artery disease was noted. In January 2009, heart disease was noted. In August 2010, an examination revealed a normal heart rate and rhythm, with no evidence of murmurs, rubs, or gallops. That same month, it was noted that the Veteran does not have a diagnosis and/or history of congestive heart failure. A June 2011 record noted a normal chest X-ray; the impression was satisfactory heart and lungs. In July 2011, the Veteran was admitted for hypertension and the assessment was coronary artery disease. In April 2009, the Veteran submitted a statement indicating that he was diagnosed with coronary artery spasm and his chest pain is of cardiac origin. In December 2009, the Veteran stated that his military records indicate he is a well-known angina patient and that angina is the most common symptom of coronary artery disease. He further stated that the evidence shows that his current heart problems are related to the bradycardia and heart attack. On June 2012 VA examination, cardiomyopathy was diagnosed. It was noted that the Veteran has a longstanding history of syncopal episodes, dyspnea with chest pain and symptomatic bradcardia that required him to have a pacemaker placed in 2007. Further, it was noted that during active duty, he had several occasions of angina and syncope in service and was diagnosed with hypertensive cardiomyopathy and sick sinus syndrome. The examiner noted that he has had a decrease in symptoms since pacemaker placement in 2007 and that he has underwent numerous left heart catheterizations that show normal coronaries and no evidence of ischemia; however, the Veteran continues to report chest pain. On physical examination, the Veteran's heart rhythm and sounds were normal. Diagnostic testing revealed no evidence of cardiac hypertrophy. It was noted that a November 2006 echocardiogram showed cardiac dilatation. Following the examination, the examiner opined that the Veteran's cardiovascular disorder was less likely than not related to service, stating that a February 2012 left heart catheterization showed no evidence of coronary artery disease with normal coronaries. The examiner stated that there cannot be a diagnosis of coronary artery disease with findings of normal coronaries via heart catheterization. In July 2013, the Board found the above rationale inadequate and remanded the matter for a new VA examination and opinion. On September 2013 VA examination, the examiner noted diagnoses of hypertensive heart disease and sinoatrial node dysfunction with bradycardia, post pacemaker insertion. His heart rhythm and heart sounds were normal. Diagnostic testing revealed evidence of cardiac hypertrophy, and no evidence of cardiac dilatation. The examiner noted that the percentage of disability that the above diagnoses contribute to cardiac dysfunction cannot be determined without resorting to speculation, especially since the heart rate is controlled with the pacemaker and the left ventricular hypertrophy is mild. Therefore, the examiner opined that each condition should be considered to contribute equally to the overall cardiac dysfunction. Following an examination of the Veteran and a review of the claims file, to specifically include the lay statements and verbal history of record, the examiner opined that it is less likely than not that the hypertensive heart disease/left ventricular hypertrophy was incurred in or caused by service. The examiner noted that there was no evidence of in-service treatment for or diagnosis of hypertension. He stated that echocardiograms start showing increased left ventricular wall thickness in 2010, and while cardiac left ventricular hypertrophy may occur after conditions such as myocardial infarction, pressure overload, idiopathic dilated cardiomyopathy or volume overload, the most common cause of concentric left ventricular hypertrophy is systemic hypertension, for which the Veteran is both diagnosed with and is treated for. Therefore, he stated that since the left ventricular hypertrophy is more than likely etiologically related to the hypertension, it is less than likely that the hypertensive heart disease/left ventricular hypertrophy was incurred in or caused by service. The examiner additionally opined that since the service-connected sinoatrial node condition has not resulted in a left ventricular pressure or volume overload condition, but rather a rhythm abnormality, which has been corrected with pacemaker treatment in August 2007, it is unlikely the service-connected sinoatrial node condition would result in left ventricular myocardial wall thickening, and for the same rationale, would also have been unlikely to have aggravated the hypertensive heart disease/left ventricular hypertrophy condition. Further, the examiner indicated that while stress tests starting in July 2008 could suggest ischemic changes, coronary angiograms in 1989, 1998, 2006 and 2012 do not indicate coronary artery disease, and that approximately 10 percent of patients undergoing nuclear isotope stress tests may have "false-positive" tests. The examiner also noted that a July 2012 cardiology note showed hospitalizations for chest pains with normal stress tests and showed that the Veteran is able to walk a mile without symptoms. This note further showed a continued diagnosis of atypical chest pain, rather than ischemic heart disease or coronary artery disease. For these reasons, the examiner stated that it is less than likely that there is ischemic heart disease or coronary artery disease. In support of his opinion, he cited two medical articles. Regarding the matter of whether any cardiovascular disorder is caused or aggravated by the Veteran's service-connected symptomatic sinus bradycardia, the examiner opined that this is less likely than not. The examiner noted that the Veteran was diagnosed with essential hypertension in 1994 or 1995 by a verbal history and in the records starting around December 2001, indicating there is no known organic cause of the hypertension. The examiner noted that echocardiograms began showing left ventricular hypertrophy starting in 2010 and continuing in 2011 and 2012. He stated that while cardiac left ventricular hypertrophy may occur after conditions such as myocardial infarction, pressure overload, idiopathic dilated cardiomyopathy, valvular disease, or volume overload, the most common cause of concentric left ventricular hypertrophy is systemic hypertension, especially since there is no history of myocardial infarction, valvular disease or cardiomyopathy. Further, the examiner indicated that since the sinoatrial node dysfunction (bradycardia) has been corrected with the pacemaker, this would improve overall cardiac function, and is unlikely to result in an increase in hypertension or other condition noted as etiological causes of concentric left ventricular hypertrophy. He stated that the service-connected bradycardia condition would cause conduction abnormalities, and without a history of congestive heart failure or dilated cardiomyopathy, there is no increase in left ventricular pressure to result in concentric left ventricular hypertrophy. Finally, the examiner noted that since the sinoatrial node condition is etiologically unrelated to the hypertensive heart disease/left ventricular hypertrophy and it has not resulted in a left ventricular pressure or volume overload condition, but rather a rhythm abnormality, which has been corrected with pacemaker treatment, it is unlikely that the service-connected sinoatrial node condition would have aggravated the hypertensive heart disease/left ventricular hypertrophy condition. In support of this opinion, the examiner cited a medical article from the National Institute of Health. The probative medical evidence simply fails to establish any nexus between his current cardiovascular disorder and the Veteran's service, to include his service-connected bradycardia. In this case, the only opinions of record are from the June 2012 and September 2013 VA examiners. As noted above, the June 2012 opinion was determined inadequate as it was not supported by a detailed rationale. Thus, the September 2013 opinion, which indicates that the Veteran's current cardiovascular disorder is not related to service, to include as due to the service-connected bradycardia, is the only probative opinion of record. This opinion was made by a medical professional following an examination of the Veteran and with citation to the factual record, including the Veteran's STRs and post-service medical records. The examiner also noted a review of the entire claims file, to include the lay statements of record. Further, he cited medical literature in support of his opinion. Because the examiner expressed familiarity with the record, and cited to supporting factual data, his opinion is probative evidence in this matter. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 299-301 (2008) ("The probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches.") quoting Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993); see also, Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Because there is no competent evidence to the contrary, it is persuasive. The Board acknowledges the Veteran's lay statements attributing his cardiovascular disorder to service, including to his service-connected bradycardia; however, although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, the etiology of a cardiovascular disorder falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer)." As such, his own assertions as to etiology have no probative value. Without evidence of the onset of a cardiovascular disorder in service or competent evidence of an association between a cardiovascular disorder and the Veteran's service, to include his service-connected bradycardia, service connection for a cardiovascular disorder is not warranted. Based on this evidentiary posture, the Board concludes that the preponderance of the evidence is against the Veteran's claim for service connection for a cardiovascular disorder. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule does not apply, and the Veteran's claim of entitlement to service connection for a cardiovascular disorder is denied. See 38 U.S.C.A. § 5107. ORDER Entitlement to service connection for a cardiovascular disorder, to include as secondary to the service-connected symptomatic sinus bradycardia, status post pacemaker insertion is denied. ____________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs