Citation Nr: 1414864 Decision Date: 04/04/14 Archive Date: 04/11/14 DOCKET NO. 08-09 749 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cheyenne, Wyoming THE ISSUE Entitlement to service connection for residuals of vasovagal syndrome. ATTORNEY FOR THE BOARD T. Hal Smith, Counsel INTRODUCTION The Veteran served on active duty from September 1987 to September 1995. This matter is before the Board of Veterans' Appeals (Board) on appeal from a December 2006 rating decision of the Denver, Colorado, Regional Office (RO) of the Department of Veterans Affairs (VA). During the pendency of the appeal, jurisdiction of the claims file was transferred to the Cheyenne, Wyoming, RO. In December 2009 and August 2010, the Board remanded the claim for additional evidentiary development. In July 2013, the Board requested an expert medical opinion from the Veterans Health Administration (VHA). 38 C.F.R. § 20.901(a) (2013). The opinion was received into the record in September 2013. As required by statute and regulation, the Board provided the Veteran a copy of the opinion and gave him time to respond to it with additional evidence or argument. See 38 C.F.R. § 20.903 (2013). In a January 2014 response, the Veteran submitted a document wherein he checked the box stating that he had no further argument and/or evidence to submit. He requested that the Board proceed with the adjudication of his appeal. Thus, this case is ready for appellate consideration. The claim on appeal was previously classified as entitlement to service connection for vasovagal syndrome. As noted on the title page of this decision, the claim has been reclassified to include entitlement to "residuals of" vasovagal syndrome as this best represents the issue on appeal. The following determination is based on review of the Veteran's claims file in addition to his Virtual VA "eFolder." FINDING OF FACT The competent evidence of record does not establish that the Veteran has a current, diagnosed, or identifiable underlying malady or condition (cardiac or otherwise) associated with his one one syncopal episode during service. CONCLUSION OF LAW Residuals of vasovagal syndrome were not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.303 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified in part at 38 U.S.C.A. §§ 5103, 5103A, and implemented at 38 C.F.R. § 3.159, amended VA's duties to notify and assist a claimant in developing the information and evidence necessary to substantiate a claim. First, VA has a duty under the VCAA to notify a claimant and any designated representative of the information and evidence needed to substantiate a claim. In this regard, September 2006, February 2010, August 2010, and November 2011 letters to the Veteran from the RO specifically notified him of the substance of the VCAA, including the type of evidence necessary to establish entitlement to service connection on a direct and presumptive basis, and of the division of responsibility between the Veteran and VA for obtaining that evidence. Consistent with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), VA essentially satisfied the notification requirements of the VCAA by way of these letters by: (1) informing the Veteran about the information and evidence not of record that was necessary to substantiate his claim; (2) informing the Veteran about the information and evidence VA would seek to provide; (3) and informing the Veteran about the information and evidence he was expected to provide. Second, VA has made reasonable efforts to assist the Veteran in obtaining evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A (West 2002 & Supp. 2013). The information and evidence associated with the claims file consist of his service treatment records (STRs), VA medical treatment records, private post-service medical treatment records, VA examination reports, and statements from the Veteran. There is no indication that there is any additional relevant evidence to be obtained by either VA or the Veteran. The Board further notes that the Veteran was accorded a VA medical examination in April 2010 and a VHA opinion was obtained in 2013. These reports, which are now part of the claims file, include opinions that addressed the etiology of the Veteran's residuals of vasovagal syndrome. Both examiners' opinions included review of the claims file. Hence, no further notice or assistance is required to fulfill VA's duty to assist in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Service Connection - In General Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty or for aggravation of preexisting injury suffered or disease contracted in the line of duty. 38 U.S.C.A. §§ 1110, 1131 (West 2002 & Supp. 2013); 38 C.F.R. § 3.303 (2013). Service connection may 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) (2013). In addition, certain chronic diseases (e.g. cardiovascular) may be presumed to have been incurred during service if the disorder becomes manifest to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1112 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.307, 3.309 (2013). The chronicity provisions are applicable where evidence, regardless of its date, show that a veteran had a chronic condition, as defined in 38 C.F.R. § 3.309(a), in service, or during an applicable presumptive period, and still has that disability. That evidence must be medical unless it relates to a condition as to which lay observation is competent. 38 C.F.R. § 3.303(b) (2013). This rule does not mean that any manifestations in service will permit service connection. To show chronic disease in service there is required 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". When the disease entity is established, there is no requirement of evidentiary showing of continuity. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (2013). The Court has held that, in order to prevail on the issue of service connection, there must be medical evidence of a (1) current disability; (2) medical, or in certain circumstances, lay evidence of inservice incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed inservice disease or injury and the present disease or injury. Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Pond v West, 12 Vet. App. 341, 346 (1999). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. Background The appellant claims that service connection should be granted for vasovagal syndrome, which he was diagnosed with after he had an episode of syncope during active service. He contends that he has continued to experience dizziness and nausea on exertion since active service. The Board notes that the appellant is competent to testify as to his ongoing symptoms since active service. The Veteran had active military service from September 1987 to September 1995. His STRs reflect that he was seen in the emergency room in April 1993 following a loss of consciousness while performing a cycle ergometry test. He reported at that time that he had neither eaten nor drunk any fluids on the day of his exercise test. The diagnosis was vasovagal syndrome. On his July 1995 separation Report of Medical History, he responded "yes" to having or having had dizziness or fainting, shortness of breath, pain or pressure in chest, and palpation or pounding heart. On the July 1995 separation examination, the appellant had a normal heart examination. An August 1995 cardiology consultation report shows that he complained of dizziness with physical exertion and positional changes. The examiner noted one syncopal event on standing up from a bicycle ergometry test. The clinical assessment was vasovagal syndrome, with a recommendation that the appellant monitor his exertion carefully, and consider a low dose beta-blocker (medication). VA treatment records dated in 2010 show that the Veteran reported having syncope and dizziness with exertion or exercise. On a VA examination in April 2010, the appellant reported that he had continued to experience dizziness and nausea on exertion since his period of active duty. As part of the VA examination, he underwent a treadmill stress test. He had a normal pulse and blood pressure response to the exercise, but a submaximal examination secondary to near syncope. The examiner noted that a March 2010 radiologic examination of the chest revealed results consistent with chronic obstructive pulmonary disease (COPD). The examiner recommended a dobutamine echo to evaluate for the presence of coronary artery disease. The diagnosis was exercise induced syncope of an uncertain etiology with no objective evidence supporting a cardiac etiology, and the examiner found that there was insufficient evidence to support a diagnosis of coronary artery disease or a cardiac arrhythmia. On an addendum opinion in October 2010, the VA examiner noted that a dobutamine cardiac echo was warranted for the appellant, but he refused the echo or additional testing. The examiner again provided a diagnosis of exercise inducted syncope, etiology uncertain. Although the VA examiner concluded that the etiology of the appellant's syncope could not be determined, and that there was no objective evidence supporting a cardiac etiology, the VA examiner did not provide commentary on whether the appellant's current syncopal episode was a vasovagal syncopal episode, like the episode manifested during his active service, or whether it was etiologically related to the episode in service. Hence, the record left unresolved the relationship, if any, between the appellant's current syncope, his reports of ongoing dizziness and nausea on exertion, and the syncope he experienced in service. Therefore, the Board found that an additional medical opinion was required. Accordingly, the Board requested additional VHA opinion regarding the medical questions on appeal. The specialist was requested to answer the question of whether it is at least as likely as not (50 percent or more probability) that the appellant's current syncopal episode(s) began to manifest during service; had been chronic and continuous (even if intermittent) since active service; or was etiologically related to his active service in any way. The medical expert was asked to include an explanation of rationale for all opinions offered, with citation to supporting factual data, as indicated. The explanation of rationale was to reflect consideration of the Veteran's assertion that he has had symptoms of dizziness and nausea on exertion since service. If any of the requested medical opinions could not be given, the expert was to state the reason(s) why this was so. The VHA opinion was added to the record in September 2013. The specialist reviewed the claims file. In the report, the specialist initially discussed various types of syncopal episodes. "Syncope" was defined as the abrupt and transient loss of consciousness associated with absence of postural tone followed by complete and usually rapid spontaneous recovery. Definitions for several type of syncope were then provided. "Neurocardiogenic syncope" was also known as common faint. This was the most common cause (25% to 62%) and had excellent prognosis with no increase in mortality or morbidity. There were 3 types of response: cardio inhibitory, vasodepressor, and mixed. Patients usually experienced a prodromal, lightheaded ness or dizziness, nausea or vomiting, warmth, pallor, etc., but this was not necessary. Examples included defecation syncope, situational syncope (e.g. during blood drawing). The diagnosis could be made based on specific history with well-known triggers such as an upright tilt table testing. "Carotid sinus hypersensitivity" was a variant of neurocardiogenic syncope due to external pressure of the carotid sinus (as during shaving or turning the head in a certain position). "Orthostatic syncope" occurred when there was a drop in blood pressure of more than 20 mmHg, or an increase in heart rate more than 20 beats per minute. This was usually caused by bleeding or dehydration or due to autonomic nervous system dysfunction. Orthostasis could occur during cardiac syncope. The frequency of this type of syncope was listed as 5-24%. "Cardiac syncope" was life threatening. Frequent episodes occurring over a short period of time, or exertional syncope were concerning for cardiac etiology. "Neurologic syncope" was rare and included subarachnoid hemorrhage, transient ischemic attack, etc. "Psychiatric syncope" included anxiety and panic disorders. Other causes or types of syncope were brought on by certain medications or were drug induced. Metabolic hypoglycemia and hypoxia could cause syncopal episodes. The VHA physician noted that the patient's medical history was usually very helpful in establishing an etiology (e.g., angina and arrhythmias in cardiac etiologies). However, it was noted the non-cardiac syncope was more common and that most patients with sudden onset of syncope had a non-cardiac cause. As for exertional syncope, it was noted that this was concerning for cardiac causes to include ventricular tachycardia, aortic stenosis, and hypertrophic cardiomyopathy. Once cardiac causes of exertional syncope were excluded, syncope was presumed to be neurocardiogenic. As to the facts of this case, the VHA physician summarized the medical findings as already reported above. In response to the question of whether it was at least as likely as not that the appellant's current syncopal episodes began to manifest during service, it was noted that his only syncopal episode occurred during service in April 1993. As to whether such had been chronic and continuous (even if intermittent) since active service, the doctor responded that his/her review of the record showed only documented syncopal episode in 1993. While there were noted in 1995 mentioning complaints of exertional "faintness" this was not supported by any other records or stress test at that time. Moreover there were no records regarding syncope or presyncope between 1995 and 2010. In 2010, the Veteran complained of persistent exertional symptoms since service, but this was the only documentation available. The physician noted that the Veteran had another treadmill test in 2010, during which presyncope was mentioned as resulting in termination of the test. There were no other symptoms (no ECG, heart rate, or blood pressure changes) to support it. Therefore, it was not possible to say for sure whether the Veteran's condition had been chronic and continuous, even if intermittent. As to the question of whether the Veteran's syncopal episodes are etiologically related to service in any way, the VHA specialist said that this remained unclear based on available data. As noted earlier, exertional syncope always needed workup for cardiac etiology. In this case, the maximal stress test in 1995 was negative. Lack of arrhythmias on both stress tests from 1995 and 2010 made arrhythmias very unlikely. Also the normal stress test from 1995 lowered the likelihood of malignant coronary anomalies or atherosclerotic heart disease. The stress test in 2010 noted presyncope with no chest discomfort or ECG changes, lowering the likelihood of coronary anomalies. It was also noted that a prior echo report excluded hypertrophic cardiomyopathy and aortic stenosis. The specialist concluded the report by noting that "statistically speaking," the most likely diagnosis was vasovagal. The Veteran's only documented syncopal episode from 1993 occurred soon after exercising, but without eating or drinking prior to it, which likely precipitated the syncope. The 2010 stress test showed a decrease in exercise time on the treadmill due to presyncopal symptoms, without other associated findings or the treadmill. It was likely the patient was fasting for a few hours prior the test as well. Thus, in the opinion of the VHA specialist, the etiology of the Veteran's condition was not related to active military service. However, "if vasovagal symptoms in his case were triggered by exercise and active duty involved active exercise, this might lead to more frequent symptoms than otherwise." Analysis As indicated above, the Veteran is seeking service connection for residuals of vasovagal syndrome. He has reported that he suffers from associated symptoms such as dizziness and nausea since his first inservice syncopal episode in 1993. He also reported heart soreness in 2010. The Board notes, however, that ongoing symptoms are not medically corroborated in the record. Specifically, the Veteran was seen for a syncopal episode during service in 1993 but testing was essentially negative as to any chronic residuals as a result. Similarly, over 15 years later, when reporting a history of exertional syncope in 2010, testing was again negative for residuals of such. This includes cardiac abnormalities of any kind. Moreover, while acknowledging that vasovagal episodes originated during service and were likely triggered by exercise, the etiology of such was unrelated to service. Moreover, the specialist noted that there were no residuals of the one documented syncopal episode during service and none were noted after testing in 2010. Testing has suggested no cardiac anomalies at any time. The evidence simply does not show that the Veteran currently has, or at any point pertinent to this appeal has had, chronic residuals as a result of the one syncopal/vasovagal episode during service. Moreover, no residuals of claimed post service syncopal episodes have been demonstrated although additional testing was conducted in 2010. Nor is there any competent evidence that he currently has, or at any point pertinent to this appeal has had, any other diagnosed or identifiable underlying malady or condition as a result of the 1993 episode or claimed post service episodes, to include a cardiac disability. Cf. Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999) ("pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted."), dismissed in part and vacated in part on other grounds, Sanchez-Benitez v. Principi, 239 F.3d 1356 (Fed. Cir. 2001). Despite the Veteran's complaints, the competent evidence of record does not reflect that residuals of vasovagal are shown. Moreover, neither the Veteran has presented or identified any competent evidence reflecting a current diagnosis of any associated disability. Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in disability. See 38 U.S.C.A. §§ 1110, 1131 (West 2002 & Supp. 2013). Thus, where, as here, medical evidence does not establish that the Veteran has a current diagnosed or identifiable underlying malady or condition associated with vasovagal syndrome, to include a cardiac disorder, there can be no valid claim for service connection. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Moreover, as for any direct assertions by the Veteran that the Veteran has current residuals of vasovagal syndrome, such assertions provide no basis for allowance of the claim. The matter of a diagnosis of neurological disability is a matter within the province of trained professionals. See Jones v. Brown, 7 Vet. App. 134, 137-38 (1994). As the Veteran is not shown to be other than a layperson without appropriate training and expertise, he is not competent to render a diagnosis on such matters. See, e.g., Bostain v. West, 11 Vet. App. 124, 127 (1998), citing Espiritu v. Derwinski, 2 Vet. App. 492 (1992). See also Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"). Hence, the lay assertions in this regard have no probative value. For all the foregoing reasons, the Board finds that the claim for service connection for residuals of vasovagal syndrome must be denied. In reaching the conclusion to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as no competent, probative evidence supports the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b) (West 2002 & 2013); 38 C.F.R. § 3.102 (2013); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Entitlement to service connection for residuals of vasovagal syndrome is denied. ____________________________________________ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs