Citation Nr: 1754066 Decision Date: 11/28/17 Archive Date: 12/07/17 DOCKET NO. 13-25 230A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for coronary artery disease. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Zi-Heng Zhu INTRODUCTION The Veteran served on active duty from August 1978 to June 1992. This matter comes before the Board of Veterans' Appeals (Board) on an appeal from an October 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The Veteran presented testimony at a Board hearing before the undersigned Veterans Law Judge in September 2016. A transcript of that hearing is of record. With regards to a claim for entitlement to service connection for a crushed middle and ring fingers of the left hand, following a notice of disagreement, the Veteran was issued a statement of the case in August 2013 that addressed service connection for the finger disability and coronary artery disease. However, subsequent to the statement of the case, the Veteran only submitted a substantive appeal in September 2013, that specifically limited the appeal to the claim for service connection for coronary artery disease. Therefore, as the Veteran did not appeal the claim for service connection for a left hand disability, that decision became final. However, subsequently, the issue of entitlement to service connection for crushed left middle and right fingers was again raised on the record during the Veteran's September 2016 testimony before the undersigned. As that may constitute an intent to file a new claim, that issue is referred to the Agency of Original Jurisdiction for appropriate response. FINDINGS OF FACT The weight of the competent evidence of record is at least in equipoise with regard to showing that currently diagnosed coronary artery disease is etiologically related to symptoms of chest pains during active service. CONCLUSION OF LAW Resolving all reasonable doubt in favor of the Veteran, the criteria for service connection for coronary artery disease have been met. 38 U.S.C.A. § 1110 (West 2014); 38 C.F.R. §§ 3.303, 3.304 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran claims that currently diagnosed coronary artery disease arose during active service, and has been persistent until the present. Specifically, the Veteran notes that during service he experienced both chest pains and pain with numbness down the left arm. The Board finds that, resolving reasonable doubt in favor of the Veteran, the evidence of record is at least in equipoise with regard to a finding that coronary artery disease is etiologically related to his chest pains and other symptoms during service. Therefore, service connection for coronary artery disease must be granted. Generally, to prevail on a claim for service connection on the merits, there must be competent and credible evidence (1) confirming the Veteran has the claimed disability or, at the very least, showing the disability at some point since the filing of the claim for the disability; (2) competent and credible evidence of in-service incurrence or aggravation of a relevant disease or an injury; and (3) competent and credible evidence of a relationship or correlation between the disease or injury in service and the presently-claimed disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection may also be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110 (West 2017). With chronic disease shown as such in service so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. However, the continuity of symptomatology language in 38 C.F.R. § 3.303(b) restricts itself to chronic diseases found in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Coronary artery disease, as cardiovascular-renal disease, is among the chronic disease under 38 C.F.R. § 3.309(a). Therefore, continuity of symptomatology may serve to establish a medical nexus. As an initial matter, the Veteran has been, and is currently diagnosed with coronary artery disease, and has had several myocardial events to include a myocardial infarction with stents. Therefore, the Veteran does has a current disability. A review of the service medical records shows that the Veteran was recorded on several occasions during service to have complained about chest pains, or pain and numbness down the left side and arm. No formal diagnosis of coronary artery disease or any heart condition was recorded during service. However, those symptoms are sufficient to constitute an in-service presence of the claimed condition during his active service if corroborated by a continuity of symptomatology or a medical opinion. The Board finds that there are both positive and negative medical opinions with regard to the etiology of coronary artery disease. The Veteran submitted several medical opinion letters from his private treating physicians, to include an October 2010 letter from Dr. J. C.; an October 2012 letter from Dr. B. Y.; and June 2014 letter from Dr. J. G. The Board finds that all three opinions ultimately conclude that the Veteran's coronary artery disease arose during active service, and was manifested during service by chest pains and pain and numbness in the left arm. All three physicians discounted the service medical record notations that only discussed possible muscular issues, and the in-service chest X-rays that noted no evidence of a heart condition. The private examiners generally noted that a chest X-ray, without follow-up testing such as an EKG, echocardiogram, or stress test, may not be dispositive of the presence of a heart condition. Therefore, the examiners found that a heart condition most likely arose during active service, when the Veteran experienced chest pain and pain and numbness on the left side. At an April 2013 VA examination, the examiner, after a review of the service medical records and medical history, concluded that coronary artery disease arose years after service, and that the Veteran's current condition was not etiologically related to any aspect of active service. The examiner noted that the in service chest pains could not be considered related to current coronary artery disease as chest X-rays during active service returned negative for issues related to the heart at the time of active service, and subsequent examinations prior to separation from service found no issues with the Veteran's heart. Therefore, the examiner concluded that the in service symptoms of chest pains and pain down the left arm were not manifestations of a heart condition, and were unrelated to the current disability. After a thorough review of the competent medical evidence of record, the Board finds that the private medical opinions of record in favor of the Veteran's claim to be more probative. Specifically, while both the VA examination and the private opinion letters have probative value, as they are both based on a review of claims file and seem to be based in sound medical reasoning, the Veteran's private physicians not only are trained in the specialty field of cardiology, but have all have had actual experience treating the Veteran's condition. They also plausibly explained why the heart condition would not have been detected in service because the types of tests that would be expected to detect that condition were not conducted. The Board finds that specialty knowledge, experience, and training in cardiology; and the familiarity with treating the Veteran gives the opinions of those private physicians higher probative value than that of a VA physician's assistant who only examined the Veteran and his records once for the purposes of the claim. Consequently, the Board finds that there is evidence sufficient to establish the Veteran's in-service symptoms of chest pains and left arm pain and numbness are etiologically related to currently diagnosed coronary artery disease. Therefore, the Board finds that the evidence is at least in equipoise, and service connection for coronary artery disease is warranted. 38 U.S.C.A. § 5107(b) (West 2014); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to service connection for coronary artery disease is granted. ____________________________________________ Harvey P. Roberts Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs