Citation Nr: 1336285	
Decision Date: 11/07/13    Archive Date: 11/13/13

DOCKET NO.  11-00 969	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in Houston, Texas


THE ISSUE

Entitlement to service connection for a heart disability, to include coronary artery disease (CAD).


REPRESENTATION

Appellant represented by:	Texas Veterans Commission


ATTORNEY FOR THE BOARD

J. All, Associate Counsel






INTRODUCTION

The Veteran had active military service in the United States Army from October 1959 to August 1960.

This case comes before the Board of Veterans' Appeals (Board) on appeal of rating decisions issued in April 2010 and November 2010 by the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas.

The Veteran requested a Board hearing, and one was scheduled for September 26, 2013; however, the Veteran did not appear.  To date, he has not requested a new Board hearing.  Accordingly, the Board considers his hearing request to be withdrawn.  38 C.F.R. § 20.704(d) (2013).


FINDING OF FACT

A heart disability, to include CAD, did not manifest in service or within one year after service separation, and the Veteran's current heart disability is not related to any disease, injury, or event in service.


CONCLUSION OF LAW

The Veteran does not have a heart disability that is the result of disease or injury incurred in or aggravated by active military service; nor may it be presumed to have been so incurred or aggravated.  38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2013).



REASONS AND BASES FOR FINDING AND CONCLUSION

Duties to Notify and Assist

When VA receives a complete or substantially complete application for benefits, it must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide.  38 U.S.C.A. §§ 5100, 5102-5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Dingess v. Nicholson, 19 Vet. App. 473 (2006).

In the instant case, VA's duty to notify has been satisfied through the notice letter dated March 2010, which fully addressed all notice elements.  This letter informed the Veteran of what evidence was required to substantiate his claim for service connection and of the Veteran's and VA's respective duties for obtaining evidence.  The Veteran has been afforded a meaningful opportunity to participate effectively in the processing of his claim and given ample time to respond.

The Board, therefore, finds that all notices required by the Veteran Claims Assistance Act (VCAA) and implementing regulations were furnished to the Veteran and that no useful purpose would be served by delaying appellate review to send out additional VCAA notice letters.

VA must also make reasonable efforts to assist the appellant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim.  38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159.

Service treatment records are associated with the claims file.  All post-service treatment records and reports identified by the Veteran have also been obtained.  The Veteran has not identified any additional records that should be obtained prior to a Board decision.  Therefore, VA's duty to further assist the Veteran in locating additional records has been satisfied.  Additionally, in April 2012, the Veteran was provided VA examination.  See 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159; Wells v. Principi, 326 F.3d 1381 (Fed. Cir. 2003).  The Board finds this examination adequate for the purpose of evaluating the claim, as it involved a review of the Veteran's pertinent medical history, a clinical evaluation of the Veteran, and an adequate explanation for the opinion provided.  See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007).

In light of the foregoing, the Board is satisfied that all relevant facts have been adequately developed to the extent possible; no further assistance to the appellant in developing the facts pertinent to the issue on appeal is required to comply with the duty to assist.  38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159.

Analysis

In general, service connection may be granted for disability or injury incurred in or aggravated by active military service.  38 U.S.C.A. § 1131; 38 C.F.R. § 3.303.  Service connection also may be granted for disability shown after service, when all of the evidence, including that pertinent to service, shows that it was traceable to disease or injury incurred or aggravated in service.  38 C.F.R. § 3.303(d).  It is not enough, however, that an injury or disease occurred in service; there must be a chronic disability resulting from that injury or disease.  To prevail on the issue of service connection, there must be competent evidence of "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; 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, 1167 (Fed. Cir. 2004).

Service connection may also be established on a presumptive basis for certain chronic diseases listed in 38 C.F.R. §3.309(a).  Unless clearly attributable to intercurrent causes, presumptive service connection may be awarded if a listed chronic disease manifests itself and is identified as such either in service or within the specified presumptive period, and the Veteran presently has the same disease.  38 U.S.C.A. § 1112; 38 C.F.R. §§ 3.307, 3.309; see Walker v. Shinseki, 708 F.3d 1331, 1336 (Fed. Cir. 2013).  If, however, a chronic disease is noted during service but is either not chronic or the diagnosis could be legitimately questioned, then a showing of continuity of related symptomatology after separation is required in order to grant service connection.  38 C.F.R. §§ 3.303(b); Walker, 708 F.3d at 1336.

The Veteran seeks entitlement to service connection for a heart disability, to include CAD.  Although the Veteran does not attribute his claimed disability to any specific incident of service, he has asserted that his heart problems began in service.  See March 2012 statement of accredited representative.

Service treatment records are silent for any heart problem or complaint, and the Veteran's entry and separation examination reports both show normal cardiovascular findings, and no diagnoses, history, or treatment of heart problems.  Furthermore, the Veteran's self-reported medical history forms, completed at entry and separation, affirmatively deny any history or complaint of heart problems.

Post-service medical evidence consists of VA treatment records.  Medical records show the Veteran received diagnoses of nonobstructive CAD and moderate to severe aortic stenosis in March 2009.  The records also show that the Veteran underwent a heart valve replacement in May 2009 at the VA Medical Center in Houston, Texas.

In April 2012, the Veteran was afforded a VA heart examination.  During the examination, the Veteran reported having had a heart murmur for "as long has he can remember."  He also reported having received VA treatment for heart problems in 2006, at which time he was evaluated by echocardiogram that indicated moderate aortic stenosis.  The Veteran's heart valve replacement surgery in May 2009 was undertaken to treat the stenosis, which had worsened over time.

The examination report reflects that the Veteran did not have ischemic heart disease, or a history of myocardial infarction, congestive heart failure, cardiac arrhythmia, infectious heart conditions, or pericardial adhesions.  Apart from the Veteran's heart valve replacement surgery, no other non-surgical or surgical procedures or hospitalizations for the treatment of a heart disability were reported.  
A chest x-ray showed post-surgical changes to the aortic heart valve, but was otherwise normal.  The examiner also reviewed the results of the Veteran's previous echocardiogram and coronary artery angiogram.  On examination, the Veteran's heart rate, rhythm, and blood pressure were within normal limits; however, a pansystolic heart murmur was detected.  The Veteran underwent an interview-based Metabolic Equivalents in Exercise Test (METs), during which he denied experiencing any of the measured symptoms at any level of physical activity.  

The examiner noted that the Veteran had had extensive cardiac evaluations to include multiple cardiac catheterizations due to his history of aortic stenosis.  With regard to the Veteran's earlier diagnosis of CAD, the examiner noted that it was not clinically significant.  Based on his review of the Veteran's pertinent medical history and results of the physical examination, the examiner opined that the Veteran's current heart disability was less likely than not related to his military service.

Entitlement to service connection on a direct basis requires competent evidence of a current disability, in-service incurrence or aggravation of a disease or injury, and medical evidence of a nexus between the current disability and service.  Based on the evidence of record, the Board finds that the Veteran has a current heart disability; however, the second and third requirements are not met.

With respect to the second requirement, there is no evidence of in-service incurrence or aggravation, and the Veteran has not cited to any in-service injury or disease.  The Veteran's service treatment records are silent for any heart problem, and his separation examination report shows normal cardiovascular findings, and no diagnoses, history, or treatment of heart problems.  Moreover, the Veteran himself affirmatively denied any heart-related problems at entry and separation.  The earliest indication of a heart disability, as shown by the medical evidence of record, was in 2006, which the Board notes is approximately 46 years following the Veteran's separation from active service.  This lapse in time weighs against the Veteran's claim.  See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000).  With respect to the third requirement, the VA examiner opined that the Veteran's heart disability was less likely as not related to his military service.

Also of record are several lay statements provided by the Veteran in support of his claim.  The Board has considered these statements.  These include an April 2010 statement from the Veteran's sister that described observed symptoms of his heart disability; an October 2010 supplemental claim wherein the Veteran asserted that his heart murmur led to his CAD; statements dated in January 2011 from his sister and a friend that discussed various health issues; and a March 2012 statement from the Veteran's accredited representative that maintained the Veteran's heart problems began in service but were not properly treated.  Additionally, the Veteran reported to the VA examiner that his heart murmur had been present for "as long as he [could] remember" and that he had it "even when he went in service."

Although the Veteran is competent to testify about his symptoms or facts or events that are within the realm of his personal knowledge, he is not competent to establish that which would require specialized knowledge or training.  Layno v. Brown, 6 Vet. App. 465 (1994).  Lay evidence may be competent to establish medical etiology or nexus in certain circumstances; however, the Board can only give lay evidence the weight to which it is entitled.  Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009).  Conclusory, generalized lay statements suggesting a nexus between a current disability and service are insufficient.  Waters v. Shinseki, 601 F.3d 1274, 1278-79 (Fed. Cir. 2010).

The Board finds the question of whether there is a relationship between a heart disability and the Veteran's military service to be complex in nature.  Although lay persons are competent to provide opinions on some medical issues, the Veteran is not competent to provide evidence with regard to more complex medical questions.  See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011).  Diseases such as CAD and aortic stenosis fall outside the realm of common knowledge of a lay person and are diagnosed and treated by professionals with specialized medical knowledge.  There is no evidence that the Veteran has the requisite medical knowledge to administer diagnostic tests, interpret test results, or attribute a heart disability to any specific 

instance of his military service.  See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007).  Therefore, while the Veteran is competent to describe his heart symptoms, he has offered only conclusory statements and is not competent to opine on the complex medical question of etiology or aggravation.

Therefore, after a review of the entirety of the evidence of record, the Board finds that entitlement to service connection cannot be granted on a direct basis.  As discussed, the Veteran's claim fails because there is no evidence of in-service incurrence or aggravation of a disease or injury, and no competent evidence of a nexus to event coincident with service.

With regard to presumptive service connection, several heart disabilities are enumerated chronic diseases under 38 C.F.R. § 3.309(a), including arteriosclerosis (coronary artery disease) and endocarditis (a term that covers all forms of valvular heart disease).  Regulations provide that where the chronic disease manifests to a degree of 10 percent within one year from the date of termination of service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service.  38 U.S.C.A. §§ 1110, 1112, 1131; 38 C.F.R. §§ 3.307, 3.309. 

Here, there is no evidence that any heart disability manifested at all within one year of August 1960, the date of separation from service.  As noted, the medical evidence of record indicates the Veteran first sought treatment for heart problems in 2006, when he learned of his moderate aortic stenosis.  While it is unclear when CAD was first manifested, neither the Veteran nor the medical evidence indicates that it predated 2006.  Consequently, entitlement to service connection on a presumptive basis must also be denied.

In sum, the Board concludes that the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for a heart disability, to include CAD.  As there is a preponderance of evidence against the claim, the benefit-of-the-doubt rule does not help the Veteran.  See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102.


ORDER

Entitlement to service connection for a heart disability, to include CAD, is denied.



________________________________
MARK F. HALSEY
Veterans Law Judge, Board of Veterans' Appeals


Department of Veterans Affairs