Citation Nr: 1742979 Decision Date: 09/27/17 Archive Date: 10/04/17 DOCKET NO. 09-13 295 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUE Entitlement to service connection for a heart disorder. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD A. Rocktashel, Associate Counsel INTRODUCTION The Veteran served on active duty for training (ACDUTRA) from May 1979 to October 1979, and on active duty from January 1980 to March 1983. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Paul, Minnesota. Jurisdiction of this case was subsequently transferred to the RO in Phoenix, Arizona. In May 2010, the Veteran testified before a Veterans Law Judge (VLJ) at a Board hearing held via videoconference. A transcript of that hearing is of record. In July 2017, the Veteran was notified the VLJ who presided at the hearing is no longer employed by the Board. The Veteran was given the opportunity to appear at a new hearing, but did not pursue this opportunity. Accordingly, the Board deems the Veteran to have declined the opportunity for a new hearing. Additional evidence has been associated with the claims file since the last RO adjudication in July 2016. This evidence is either duplicative of the evidence already of record, or it is not pertinent to the issue on appeal. Therefore, RO consideration of the evidence in the first instance is not necessary and the Board can proceed with adjudication of the case on the merits. In July 2010, August 2014, April 2016, the Board remanded this matter for further evidentiary development. The requested development was completed, and the case was and has been returned to the Board for further appellate action. In December 2015, the Veteran submitted a Notice of Disagreement (NOD) as to a December 2015 rating decision denying service connection for a left shoulder disorder. The RO has not issued a statement of the case (SOC) with respect to the foregoing NOD. The RO has, however, scheduled the Veteran for a VA examination and obtained a medical opinion in April 2017. As the RO appears to be actively processing the appeal and there is development that is uncompleted, the Board declines to take jurisdiction of the issues for the purpose of issuing an SOC. FINDING OF FACT A heart disorder was not manifest during service and is not attributable to service. CONCLUSION OF LAW A heart disorder was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2016). REASONS AND BASES FOR FINDING AND CONCLUSION VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014); Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012, Pub. L. No. 112-154, §§ 504, 505, 126 Stat. 1165, 1191-93; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2016). In a May 2016 correspondence, the Veteran contended in essence that the May 2016 VA medical opinion was based on inaccurate facts. The Board finds that the May 2016 VA medical opinion is factually consistent with the other evidence of record, including service treatment records and private medical records from 1996. The examiner was not required to provide an examination according to the April 2016 Board remand, and instead was permitted to provide a medical opinion, unless in his judgement an examination was required. The examiner did not require an examination in this instance. In combination with the previous medical examination in May 2008, and the previous medical opinions, the Board finds the duty to provide an adequate examination has been satisfied. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Otherwise, neither the Veteran nor his representative have raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Analysis Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009). Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In July 2007, the Veteran submitted a claim of service connection for congestive heart failure. He asserted that it began in boot camp for the Marine Corps. At the May 2010 Board hearing, the Veteran testified about having chest problems during his fourth week of Marine Corps boot camp in May or June of 1979. Upon examination, the doctor found a murmur and asked the Veteran if he wanted to go home. The Veteran's drill instructor did not permit him to go home, but instead had him finish boot camp wearing a T-shirt indicating he was at medical risk. The Veteran ultimately passed his second phase physical fitness test, and was deemed physically fit to continue. The Veteran testified that over the next couple of years, he went to sick bay about 7 or 8 times complaining of heart problems. He reported that he had a heart attack in 1996, and stated that he had recently found out that he was born with cardiomyopathy. He asserted that service aggravated this preexisting heart condition. The Veteran also testified that after service, he did not go to see a doctor about his heart until the heart attack in 1996. The Veteran further testified that in January 2009 he had surgery prior to which time an imaging study was performed which showed that his heart doesn't "pump like everybody else's," and that he has a web-like design on the side of his heart and a hole that could only be seen recently because the technology is only about 6 or 7 years old. The record in this case shows that in service, the Veteran reported cardiac symptoms such as shortness of breath, chest pain, pounding heart, and heart trouble on his entrance report of medical history in January 1980. He was evaluated for a heart murmur. At that time, the Veteran said he had been told he had a heart murmur when he was 11. The assessment was that the Veteran had a flow murmur. The January 1980 report of medical examination found the Veteran had sinus bradycardia which was not considered disabling. The examination report also noted that an electrocardiogram was within normal limits. The Veteran was seen in April 1980 with complaints of a sharp, stabbing chest pain that came and went. He could localize the area with one finger. The examination was unremarkable and the conclusion was thoracic gas pain. He was also seen in June 1980 for complaints of body aches, malaise, sore throat, dry cough, headache, and shortness of breath with sharp pain when coughing. He was found to have a viral upper respiratory infection. The Veteran was then seen in July 1980 with chest pain, shortness of breath, dizziness, headache, and cough since that morning. The record states that he had had two immunizations that morning (plague and cholera). He was described as being very agitated and the note mentions that he was a poor historian. His examination was essentially unremarkable. He was felt to have a viral upper respiratory infection and symptoms related to immunizations. In October 1980, the Veteran was seen for dizzy spells with "pin like" chest pains that morning. The record stated that "after talking to the patient, he has not eaten properly and the pain in his chest is not really there but he thinks he has heart trouble." His examination was normal. The February 1983 separation examination report revealed a normal clinical evaluation of the heart. Post-service, January 1998 private medical records report that in 1996, the Veteran was seen at a hospital for a severe headache. He was treated in the emergency department with Imitrex and was also given dihydroergotamine. During the infusion medication, the Veteran became restless, short of breath, hypertensive, complained of chest pain, and went into pulmonary edema. His electrocardiogram showed abnormalities, and his treatment required intubation and several days in the coronary care unit. The Veteran recovered from this event without any major sequelae, according to the medical record. He continued to improve, and in March 1996, he underwent diagnostic coronary angiography. The study demonstrated normal coronary arteries; the ejection fraction was mildly reduced to 52; there was anterolateral wall hypokinesia and hypokinesia of the diaphragmatic segment. He was given a diagnosis of acute ischemia and subendocardial infarction secondary to vasoconstriction effect of sumatriptan and dihydroergotamine, and pulmonary edema and hypertension secondary to this ischemic event. Since that time, had five to six emergency department visits, secondary to chest pain and some of them requiring nitroglycerin. The record noted there was no evidence or record if the Veteran had any myocardial ischemia or elevated enzymes at the time of hospitalization. The overall echocardiogram was normal. The examiner's impression was that his left ventricle recovered without any significant wall motion abnormalities. A February 1998 coronary angiogram revealed normal coronary arteries. There were small fistulas between the coronary arteries and the left ventricle, which were found to have no clinical significance. The coronary flow status was normal. A May 2008 VA examination was performed. The Veteran's history was reviewed. It was specifically noted that a murmur was found on active duty, but no evidence of heart disease. The examiner also noted the myocardial infarction in 1996. The Veteran described reduced exercise tolerance and occasional episodes of atypical chest pain. After a review of the evidence and examination, the examiner opined that the Veteran's heart condition was not caused by or a result of chest pain in service. The given rationale was the likeliness of a post-service cause (namely adverse reaction to several medications given for migraine headache), and the findings in the service treatment records that chest pain symptoms were non-cardiac. A December 2008 cardiac magnetic resonance imaging (MRI) study resulted in normal findings for the most part. There was a notation that there is a somewhat web-like myocardium with prominent apical trabecula, almost meeting criteria for non-compaction. A March 2009 report of an informal conference with the Veteran, his representative, and an RO Decision Review Officer notes that the Veteran agreed that the acute ischemia and subendocardial infarction noted in his private treatment records in 1996 was secondary to the effect of a combination of medication and has nothing to do with his current claim. An August 2010 VA medical opinion found no diagnosis because, although there were symptoms, there was no current clinical objective evidence of disease or pathology. The examiner reasoned that the December 2008 magnetic resonance imaging did not show any evidence of cardiomyopathy ventricular hypertrophy. The examiner explained that this is a more sensitive and specific test than an echocardiogram. The examiner listed other studies and examination results that found no evidence of murmur. The examiner further reasoned that cardiac murmurs in young, otherwise healthy people are not unusual and rarely lead to long term sequalae. The examiner further found that there was no functional impairment. A June 2011 VA medical opinion as to the Veteran's claim held that cardiomyopathy was not caused by military service. The rationale was there was no current evidence of ischemic heart disease, although there was possible past ischemic heart disease as a result of coronary artery spasming. The examiner noted that an exercise stress test done in December 1997 did not show evidence of ischemic heart disease. October 2014 VA medical opinion related to the heart disorder was obtained. The examiner noted the Veteran's in-service finding of a flow murmur. The examiner explained that a murmur can be a sign of turbulent blood flow through the heart due to a structural abnormality, but it is very commonly an "innocent" flow murmur not associated with pathology. Instances in-service of the Veteran complaining about symptoms such as chest pain and shortness of breath turned out not to be related to the heart, according to the examiner. Later, post-service, echocardiograms established that the patient did not have structural abnormalities. Based on review of the available medical information, the examiner found that there was no evidence that the Veteran had any type of pathologic cardiac condition during military service. No post-service heart disorder diagnoses, including cardiomyopathy, represents a residual of any in-service disorder or represents a chronic disorder that began in service. A May 2016 VA medical opinion held that the Veteran does have a current heart disorder, namely, myocardial injury. However, the examiner opined that the current disorder is not related to military service, did not begin in military service, is not related to any in-service disorder, and is not aggravated beyond its natural course by any in-service disorder. The examiner noted the Veteran's in-service finding of a low pitched systolic murmur, with a diagnosis of flow murmur. The examiner found this to be "a physiologic, not pathologic condition." The examiner recited the evidence showing the 1996 admission to the emergency department for severe headache, which resulted in the assessment of acute ischemia and subendocardial myocardial infarction, possibly secondary to coronary spasm, cardiomyopathy New York Heart Association (NYHA) class I and tobacco abuse. The examiner reasoned that the Veteran's cardiac condition was diagnosed in 1996. It was attributed to specific pharmacotherapy given at that time that could induce vasoconstriction, and has no relationship with conditions while in service. A review of the VA treatment records shows notations of a history of cardiomyopathy. A December 2010 record reported the Veteran complains of palpitations when he doesn't take his antidepressant medication. Based on a review of the record, the Board finds that service connection for a heart disorder is not warranted. In this regard, the Board finds the Veteran had a heart murmur in service, but it is not related to the current heart disorder, mild cardiomyopathy, which had its onset in 1996 after an adverse reaction to a combination of medications. Service treatment records report a flow murmur, but are otherwise normal. The separation examination showed a normal clinical evaluation of the heart. Later, VA medical opinions assert that a flow murmur is likely benign. See October 2014 and May 2016 VA medical opinions. The Veteran's in-service complaints relating to heart symptoms were assessed as non-cardiac in origin. Finally, the Veteran's 1996 myocardial infarction was the source of the current heart disorder, which in itself is not definitively established. In his Board hearing, the Veteran testified that he did not seek treatment for his heart until he had the 1996 myocardial infarction. The foregoing are highly probative facts against a link between the in-service heart murmur and the current disability. The Board further finds that the Veteran did not have cardiomyopathy in service. As noted above, the separation examination finding was normal. The preponderance of the evidence shows that the finding of a flow murmur is an innocent physiologic condition. See October 2014 and May 2016 medical opinions. Cardiomyopathy was not found until many years after service. Thus, the issue of aggravation of a pre-existing condition is not applicable. In considering the foregoing, the Board acknowledges the Veteran's lay statements that he found out that he had cardiomyopathy in service, that his heart does not beat like everyone else's and that he has a hole in his heart. The Board finds these, and other lay statements by the Veteran, to be less credible and probative than the objective medical records and the VA examiners' opinions. The written medical records are more probative because they are recorded outside the context of a claim for compensation by those with skills and experience in the medical profession. Similarly, the VA examiners' opinions are more probative because the examiners are professionals with training in the medical field and experience assessing medical etiologies. Based on the foregoing, a preponderance of the credible evidence is against a finding that the current heart disorder is related to service. Accordingly, service connection is not warranted. Although the Veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit of the doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim. ORDER Service connection for a heart disorder is denied. ____________________________________________ D. Martz Ames Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs