Citation Nr: 1756867 Decision Date: 12/08/17 Archive Date: 12/15/17 DOCKET NO. 14-10 220 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to service connection for a cardiac disability, to specifically include first degree atrioventricular (AV) block. 2. Entitlement to service connection for cardiac disabilities, to specifically exclude first degree atrioventricular block. 3. Entitlement to service connection for a left thigh disability, to include peripheral artery disease (PAD). ATTORNEY FOR THE BOARD Rachel Mamis, Associate Counsel INTRODUCTION The Veteran had active air service from May 1975 to May 1995. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a May 2011 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. In his February 2014 substantive appeal, the Veteran originally requested that he be afforded a hearing before a member of the Board. However, it appears that prior to submission, the Veteran indicated that wished to withdraw his request for a hearing by so indicating on the Veteran's substantive appeal documentation. FINDINGS OF FACT 1. A cardiac disability, to include first degree AV block is etiologically related to active service. 2. A cardiac disability, to exclude first degree AV block, is not etiologically related to the Veteran's active service. 3. A left thigh disability is not etiologically related to the Veteran's active service. CONCLUSIONS OF LAW 1. A cardiac disability, to include first degree atrioventricular (AV) block, was incurred in or aggravated by active service. 38 U.S.C. §§ 1101, 1110, 1112, 1131 (2017); 38 C.F.R. §§ 3.303, 3.304, 3.309 (2017); Diagnostic Code 7015. 2. A cardiac disability, to exclude first degree atrioventricular block, was not incurred in or aggravated by active service and the incurrence or aggravation of during active service may not be presumed. 38 U.S.C. §§ 1101, 1110, 1112, 1131 (2017); 38 C.F.R. §§ 3.303, 3.304, 3.309 (2017); D.C. 5399-5321. 3. A left thigh disability, to include peripheral artery disease (PAD) was not incurred in or aggravated by active service. 38 U.S.C. §§ 1101, 1110, 1112, 1131 (2017); 38 C.F.R. §§ 3.303, 3.304, 3.309, 3.310 (2017); D.C. 7114. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Entitlement to Service Connection for Cardiac Disabilities The Veteran asserts that he is entitled to service connection for a cardiac disability, to include coronary artery disease and/or coronary vasospasm, also known as Prinzmetal's angina. More specifically, the Veteran asserts that his currently diagnosed coronary artery vasospasm and or coronary artery disease had its onset in service with the diagnosis of first degree atrioventicular block. The Veteran's service treatment records (STRs) are silent for diagnosis or treatment for either coronary artery disease or Prinzmetal's angina. The Board notes that the Veteran was diagnosed with a first degree atrioventricular block while in service, as confirmed by the Veteran's STRs. More specifically, a note in the Veteran's STRs report that the Veteran was diagnosed in approximately December 1991 with a first degree AV block on resting electrocardiogram (EKG), with a heart rate of 41. He was provided further testing to rule out additional cardiac disabilities, as well as to determine any physical limitations from his diagnosed AV block. At the time of the Veteran's diagnosis, it was noted that he denied experiencing angina (chest pain). The additional testing was noted to be negative for evidence of cardiac ischemia or cardiac arrhythmias. He was noted to exhibit good exercise tolerance. The Veteran was afforded a VA examination in March 2016 to determine the nature and etiology of any existing cardiac disabilities. In particular, the examiner was asked to opine as to whether the Veteran's post service coronary vasospasm or coronary artery disease (CAD) had their onset in service, manifested by the diagnosed AV block. The examiner opined that the Veteran's currently diagnosed cardiac conditions were less likely than not (less than 50% probability) incurred in or caused by the in-service injury, event or illness, including the diagnosed first degree AV block. The examiner reasoned that the Veteran's subsequently diagnosed vasospasm and CAD are not consistent with a diagnosis of first degree AV block. The examiner noted that the Veteran's medical evaluations revealed normal coronary arteries with reported "suboptimal flow", and that as recently as September 2012, there was no evidence of any ischemia or interruption of blood flow to the heart caused by blockages, as would be expected with CAD. The examiner also noted there was no evidence of any coronary, peripheral or cranial vasospasms consistent with the diagnosis of coronary vasospasm. The examiner further explained that AV blocks can occur in those with structural cardiac abnormalities, as well as in well-trained athletes who participate in strenuous exercise. On that basis, she opined that the Veteran's AV block was caused by his high level of physical activity in the Air Force, and not coronary artery disease or vasospasms. In the Veteran's STRs, it was noted that through at least February 1990, that the Veteran regularly engaged in an exercise program, to specifically include running. In the Veteran's May 2016 notice of disagreement, he confirmed that he regularly ran 3 to 5 miles a day through his period of active duty, outside any physical fitness requirements imposed by the Air Force. The Board notes that the Veteran currently receives treatment at the VA Medical Center for his disabilities, including his cardiac conditions. At a visit in February 2012, the Veteran reported the onset of chest pain to only the last few years, roughly fifteen years following the Veteran's discharge. At a visit in September 2012, Dr. D.G. noted the Veteran's recent cardiac catheterization revealed no coronary artery disease. He also noted the cardiac study was negative for cranial, or peripheral vasospasms, and the finding were otherwise negative for "true angina". A May 2011 perfusion study revealed no evidence of any cardiac ischemia or evidence of a myocardial infarction (heart attack). The Veteran's ejection fraction was measured at 60 percent. In the Veteran's May 2016 notice of disagreement, the Veteran confirmed his diagnosis of coronary vasospasm, as diagnosed in approximately September 2012, close to twenty years following discharge from service. He relayed the medical provider's opinion that the diagnosis of coronary vasospasm could explain the onset of chest pain following service. However, the medical provider did not provide a nexus between the diagnosis of coronary vasospasm to any in-service injury, event or illness, or to the Veteran's already diagnosed first degree AV block. While the Veteran is competent to report symptoms of chest pain, he is not competent to make a diagnosis of a cardiac disability or to provide a nexus opinion linking any cardiac disability, including coronary vasospasms or CAD to service, including to the diagnosed first degree AV block, as that requires medical testing and expertise that is outside the realm of common knowledge of a layperson. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Therefore, the Veteran is not competent to provide a nexus opinion in this case, specifically with regard to the claim for entitlement to service connection for coronary vasospasms and/or CAD. This is a complex case: The Board notes that there is no competent evidence of record indicating that the Veteran's cardiac disabilities, to specifically include coronary vasospasms and/or CAD is related to his active service, or related to the Veteran's diagnosed first degree AV block, and some evidence against such a finding. Therefore, the claim for entitlement to service connection for cardiac disabilities, to exclude first degree AV block is denied. However, the Board concedes that the VA examiner has opined that the Veteran's first degree AV block, which had its onset in service, could have been caused by his strenuous physical exercise in the military. As noted above, the Veteran's STRs confirm a regular regimen of physical exercise throughout his twenty year period of active duty. Therefore the Board finds that the preponderance of the evidence is for the claim for a cardiac disability, to specifically include first degree AV block and the claim is granted. 38 U.S.C. §5107(b) (2012); Gilbert v. Derwinski, 1 Vet App. 49 (1990). Entitlement to Service Connection for a Left Thigh Disability The Veteran asserts that he is entitled to service connection for a left thigh disability, manifested by left thigh pain. The Veteran's service treatment records (STRs) are silent for diagnosis or treatment for a left thigh disability. During a February 1981 examination, the Veteran's lower extremities were noted to be normal upon clinical evaluation. A February 1988 and January 1995 examination, just prior to the Veteran's discharge from active duty also revealed normal lower extremities upon clinical evaluation. In the Veteran's May 2015 notice of disagreement, he stated that the thigh pain began in approximately 1990. He noted that that the pain began predominantly following strenuous exercise. The Board notes that the Veteran currently receives treatment at the VA Medical Center for his disabilities, including management of his thigh pain. A September 2010 MRI revealed no structural or muscular abnormalities, including no evidence of masses or edema. At a visit in April 2014, the Veteran reported pain, manifested by numbness in his left thigh. Upon objective examination, the Veteran exhibited no lower extremity weakness. The Veteran denied numbness in any other areas. He reported the pain was worse after running or prolonged standing. The medical provider hypothesized the pain was possibly musculoskeletal given the Veteran's physical exercise, or radicular in nature, with no final assessment or diagnosis provided. A May 2014 lower extremity sonogram revealed normal compressibility and augmentation of the femoral and popliteal veins. There was no evidence of any cysts, or lower extremity blood clots which would explain the Veteran's thigh pain. During a neurology visit in August 2014, the Veteran denied paresthesias or radicular symptoms. The medical providers noted that the recent EMG revealed no motor or sensory abnormalities. Upon objective examination, the Veteran's extremities were noted to be normal, without evidence of edema or cyanosis. Strength was equal bilaterally and the Veteran's neurological examination was otherwise normal. The neurologist noted there was no evidence of any long fiber or feet symptoms to suggest a diagnosis of a neurological nature. He likewise hypothesized the pain was possibly musculoskeletal in nature and suggested referral to an orthopedist. At a visit in December 2014, the Veteran continued to complain of left posterior thigh pain. The medical provider notes the evidence of record was negative for radiculopathy, or any muscular abnormalities, per the Veteran's September 2010 MRI. While the Veteran is competent to report symptoms of thigh pain, he is not competent to make a diagnosis of a thigh disability or to provide a nexus opinion linking any thigh pain to service, as that requires medical testing and expertise that is outside the realm of common knowledge of a layperson. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Therefore, the Veteran is not competent to provide a nexus opinion in this case. For a disability to be service connected, it must be present at the time a claim for VA disability compensation is filed or during or contemporary to the pendency of the claim. McClain v. Nicholson, 21 Vet. App. 319 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). There is no evidence of record showing the Veteran to have a confirmed diagnosis of any left thigh, or left lower extremity pathology at any point during the appeal period. Congress has specifically limited entitlement to service-connected benefits to cases where there is a current disability. In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223 (1992). The Board acknowledges that a VA medical examination or medical opinion has not been obtained in response to the claim. The Board also finds the Veteran has been provided adequate assistance in response to the claims. VA is obliged to provide a VA examination or obtain a medical opinion when: (1) there is competent evidence that the Veteran has a current disability (or persistent or recurrent symptoms of a disability), (2) there is evidence establishing that the Veteran suffered an event, injury or disease in service or has a disease or symptoms of a disease within a specified presumptive period, (3) the evidence indicates that the current disability or symptoms may be associated with service or with another service-connected disability, and (4) there is not sufficient medical evidence to make a decision. 38 C.F.R. § 3.159(c)(4) (2017); Charles v. Principi, 16 Vet. App. 370 (2002). There is no competent evidence of record indicating that the Veteran's thigh pain is related to his active service. The Veteran's service treatment records are of record. VA and private treatment records have been obtained. Therefore, the Board finds that the medical evidence currently of record, which is very expensive, is sufficient to decide the claim and a VA examination or medical opinion is unnecessary. The Veteran has not identified any outstanding evidence, to include medical records, which could be obtained to substantiate the claim. The Board is also unaware of any outstanding evidence. Accordingly, the Board finds that the preponderance of the evidence is against the claim, and entitlement to service connection for a left thigh disability, is not warranted. 38 U.S.C. § 5107(b) (2017); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to service connection for a cardiac disability, to specifically include first degree AV block, is granted. Entitlement to service connection for cardiac disabilities, to specifically exclude first degree AV block, is denied. Entitlement to service connection for a left thigh disability is denied. JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs