Citation Nr: 1336753 Decision Date: 11/12/13 Archive Date: 11/22/13 DOCKET NO. 13-03 204 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUE Entitlement to service connection for a cardiovascular disorder, claimed as secondary to a service-connected gastrointestinal disability. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Shamil Patel, Counsel INTRODUCTION Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2013). 38 U.S.C.A. § 7107(a)(2) (West 2002). The Veteran served on active duty from January 1949 to February 1952. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. The Veteran testified at a hearing in June 2012 held at the RO before a Decision Review Officer (DRO). The matter was previously remanded by the Board in July 2013 for additional development, and now returns for further review. FINDING OF FACT The Veteran's coronary artery disease is not caused by, aggravated by, or otherwise related to his service-connected postgastrectomy syndrome with history of duodenal ulcer disease. CONCLUSION OF LAW The criteria for service connection for a cardiovascular disorder have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. § 3.303, 3.307, 3.309, 3.310 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION Veterans Claims Assistance Act of 2000 Under the Veterans Claims Assistance Act (VCAA), 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 C.F.R. § 3.159 (2013). Here, the Veteran was provided with the relevant notice and information in a June 2011 letter prior to the initial adjudication of his claim. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). He has not alleged any notice deficiency during the adjudication of his claim. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). VA also has a duty to assist the Veteran in obtaining potentially relevant records, and providing an examination or medical opinion when necessary to make a decision on the claim. Here, the Veteran's service records, VA records, and identified private treatment records have been obtained and associated with the claims file. The Veteran was also provided with VA examinations which, collectively, contain a description of the history of the disability at issue; document and consider the relevant medical facts and principles; and provide opinions regarding the etiology of the Veteran's claimed condition. VA's duty to assist with respect to obtaining relevant records and an examination has been met. 38 C.F.R. § 3.159(c); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Finally, the Veteran testified at an RO hearing. The hearing was adequate as the DRO who conducted the hearing explained the issue and identified possible sources of evidence that may have been overlooked. 38 C.F.R. 3.103(c)(2); Bryant v. Shinseki, 23 Vet. App. 488 (2010). Service Connection The Veteran has not asserted that his cardiovascular disability is related to his period of active service, and his service treatment records do not reflect a finding of any cardiovascular diagnoses or complaints. Therefore, service connection for a cardiovascular disability as directly related to service is not appropriate. Rather, the Veteran contends that he has a cardiovascular disability that is secondary to his service-connected gastrointestinal disorder, including anemia associated with his gastrointestinal disorder. Service connection is warranted for a disability which is proximately due to, aggravated by, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (2013). In this case, the Veteran's treatment records and VA examinations clearly document both his coronary artery disease, with a history of myocardial infarction and bypass surgery in August 2001, as well as his service-connected postgastrectomy syndrome with associated anemia. However, the overall weight of the evidence is against a finding that the gastrointestinal disorder proximately caused or aggravated the Veteran's coronary artery disease. A finding of secondary service connection requires competent medical evidence to connect the asserted secondary disability to the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Velez v. West, 10 Vet. App. 432 (1997). The probative value of medical opinion evidence is based on a medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches. Guerrieri v. Brown, 4 Vet. App. 467, 470 (1993). The credibility and weight to be attached to these opinions is within the province of the Board. Id. VA treatment records dated November 2010 noted that iron-deficiency anemia of the magnitude demonstrated by the Veteran can cause a heart attack. While this statement suggests an etiological nexus between anemia and a cardiovascular condition, the statement is not accompanied by any supporting rationale or explanation. Therefore, the probative value of that statement is limited. Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). In contrast, an August 2013 VA opinion stated that the Veteran's cardiovascular disorder was not caused by or aggravated by the service-connected gastrointestinal disability and associated iron deficiency anemia. In addition to a review of the claims file and an examination of the Veteran, this conclusion was also based on medical literature which did not reveal anemia to be etiologically tied to the development of coronary artery disease. Physiologically, anemia does not cause narrowing of coronary arteries, and there is no pathophysiologic mechanism where anemia would otherwise cause or lead to coronary artery disease. Anemia was also not a condition contributing to the Veteran's report of myocardial infarction in 2001. It is not considered a risk factor for myocardial infarction, and the evidence does not show anemia prior to the Veteran's coronary artery bypass in August 2001. The examiner also stated that while there had been times when the Veteran had anemia and developed shortness of breath, there is no evidence angina, cardiogenic syncope, or myocardial infarction that occurred related to anemia. No cardiac condition was diagnosed as a result of the Veteran's anemia either being treated when found or during an acute event of anemia being discovered. The August 2013 opinion is also supported by a December 2012 VA opinion, which did not address the element of aggravation, but noted that the Veteran had several risk factors for coronary artery disease, including hyperlipidemia, being a male over the age of 45, a prior history of tobacco use, and hypertension. This examiner stated that duodenal ulcers, gastrectomy, and iron-deficiency anemia were not known risk factors for the development of coronary artery disease. The Board has also considered the Veteran's own statements, including his hearing testimony, made in support of his claim. However, he has not demonstrated any specialized knowledge or expertise to indicate he is capable of rendering a competent medical opinion. Although lay persons are nonetheless 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 coronary artery disease, including any relationship to anemia or a gastrointestinal disability, 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). Therefore, the Veteran's statements are not competent evidence of a medical nexus between his claimed condition and his service-connected disability. Because they are supported by detailed explanations, the Board finds the December 2012 and August 2013 opinions to be the most probative evidence in determining the etiology of the Veteran's coronary artery disease. For this reason, the overall weight of the evidence is against finding a relationship or nexus between the Veteran's coronary artery disease and his service-connected gastrointestinal disability. The appeal is accordingly denied. In making this determination, the Board has considered the provisions of 38 U.S.C.A. § 5107(b) regarding benefit of the doubt, but there is not such a state of equipoise of positive and negative evidence to otherwise grant the Veteran's claim. ORDER Service connection for a cardiovascular disorder is denied. ____________________________________________ P. M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs