Citation Nr: 1806249 Decision Date: 01/31/18 Archive Date: 02/07/18 DOCKET NO. 11-20 377 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUE Entitlement to service connection for a heart disorder, to include cardiomyopathy, hypertensive heart disease, and left bundle branch block, to include as secondary to in-service herbicide exposure. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD S. Keyvan, Counsel INTRODUCTION The Veteran served on active duty from October 1962 to May 1983. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. In October 2013, the Veteran testified during a hearing at the Muskogee RO before the Board. A transcript of the hearing is of record. In October 2014 and February 2017, the Veteran's claim was remanded for additional development. FINDING OF FACT The Veteran's heart disorder, diagnosed as cardiomyopathy, did not manifest during service, or within one year of separation and was not shown to be attributable to any incident or event of his period of service, to include as a result of his exposure to herbicide in service. CONCLUSION OF LAW The criteria for service connection for a heart disorder, to include as due to herbicide exposure, have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1116, 1131, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist With respect to the Veteran's claim herein, VA has met all statutory and regulatory notice and duty to assist provisions. See generally, 38 U.S.C. §§ 5103, 5103A (2012); 38 C.F.R. § 3.159, 3.326 (2017). Pursuant to the October 2014 Board remand, the Veteran's medical records issued by his private physician, Dr. D.S. at Oklahoma Cardiovascular Associates, and dated from 2008 to 2014, have been retrieved and associated with the claims file. In correspondence received in December 2014, the Release of Information Department at Oklahoma Heart Hospital indicated that there were no additional medical records at their facility pertaining to treatment provided for the Veteran from October 2014 to the present. In addition, pursuant to the October 2014 remand instructions, the Agency of Original Jurisdiction (AOJ) requested from the National Personnel Records Center (NPRC), any inpatient and/or outpatient hospital records from the Naval Weapons Center China Lake California Base Hospital documenting treatment for the Veteran's symptoms of chest pain in service sometime between 1980 and 1981. In a July 2015 letter, the AOJ informed the Veteran that they had received a negative response from the NPRC reflecting that a search for inpatient clinical records, dated from January 1980 to December 1980, and pertaining to treatment provided for the Veteran's chest pain from the Naval Weapons Center China Lake, California Base Hospital was negative. In the February 2017 remand, the Board instructed the AOJ to, once again, request from the NPRC both the inpatient and/or outpatient hospital records from the Naval Weapons Center China Lake, California Base Hospital which documented treatment for the Veteran's symptoms of chest pain between January 1981 and December 1981. Pursuant to this remand directive, in the March 2017 Request for Information under PIES (Personnel Information Exchange System), the AOJ requested these records. The May 2017 response reflected that no search was possible based on the information furnished and that the index of retired records at the NPRC did not include any pertinent treatment records reflecting treatment for the Veteran's chest pain at China Lake, California Base Hospital in 1981. In a July 2017 letter addressed to the Veteran, the AOJ listed the various attempts made to locate these particular service treatment records. The AOJ further noted that all efforts to retrieve this information had been exhausted, and based on these facts, any further attempts to secure these records were futile. In addition, a more recent VA medical opinion which addressed the etiology of the Veteran's claimed heart disorder and whether it was related to his military service, to include his in-service herbicide exposure, was issued in November 2014-the report of which has been associated with the claims file. Based on a review of the record, the Board finds that the AOJ has substantially complied with both the October 2014 and February remand directives, and no further action is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). Analysis Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303(a) (2017). "To establish a right to compensation for a present disability, a Veteran must show '(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service'-the so-called 'nexus' requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection for certain chronic diseases may also be established based upon a legal "presumption" by showing that the disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1112, 1137 (2012); 38 C.F.R. §§ 3.307, 3.309 (2017). In addition, service connection may be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2017). The Veteran contends that his current cardiovascular problems arose in service. Specifically, the Veteran contends that he began experiencing, and was treated for, chest pain in service, and these medical problems were early manifestations of his current heart disorder. The Veteran further contends that his exposure to herbicides and various other chemicals, while working at an Aviation Hydraulic shop early on during his military career, and while working at a paint shop, led to his current heart problems. See Statements of Veteran, one of which is dated in July 2011, and the other of which is date stamped as received in August 2012. Turning to the service treatment records, the Board notes that the clinical evaluation of the Veteran's heart, endocrine and vascular system was shown to be normal at the October 1962 medical examination conducted pursuant to his enlistment into service. In addition, the Veteran denied a history of heart trouble, high or low blood pressure, or pain or pressure in his chest in his medical history report. The remainder of the service treatment records is absent any complaints of, or treatment for heart problems. At the January 1983 separation examination, the clinical evaluation of the heart, endocrine, and vascular system was shown to be normal. Although the Veteran reported a history of pain or pressure in his chest, he denied a history of heart trouble and high or low blood pressure. According to the Veteran, he was admitted to the Naval Weapons Center China Lake California Base Hospital in late 1980 or early 1981 with complaints of severe chest pain. He recalled undergoing an echocardiogram while there, and being placed on medication to help alleviate his symptoms. The Veteran described feeling excessively tired on a regular basis, and requiring frequent naps throughout the day to help keep him energized after this incident. The Veteran further recounted how he continually failed the Annual Physical Fitness tests administered by the military after this incident. See July 2011 and August 2012 Statements of the Veteran During his hearing, the Veteran testified that he has experienced symptoms of heart problems, to include fatigue and shortness of breath since experiencing, and receiving treatment for, chest pain in service. See October 2013 Hearing Transcript (T.) pp. 10-11. The post-service treatment records reflect that the Veteran underwent an electrocardiogram (EKG) at the VA medical center (VAMC) in Amarillo, Texas in April 2008, the findings of which were shown to be abnormal and specifically reflected findings of left axis deviation and left bundle branch block. In a June 2008 letter, the Veteran's private physician at Oklahoma Cardiovascular Associates, D.S., M.D., noted that the left bundle branch block pattern was probably benign. He also noted that the Veteran exhibited dyspnea with exertion, which worsened during certain activities and weather. The Veteran subsequently underwent another EKG, the results of which showed moderately dilated left ventricle and severely reduced left ventricular (LV) systolic function. The Doppler analysis revealed mild mitral regurgitation, and mild tricuspid regurgitation. VA treatment records dated from June 2009 to June 2010 reflect diagnoses of cardiomyopathy with estimated ejection fraction between 30 to 40 percent, and a history of congestive heart failure. The Veteran was afforded a VA (QTC) examination in February 2010, at which time he provided his medical history and described ongoing symptoms of shortness of breath, dizziness and fatigue arising from his current heart condition. Results from the EKG revealed sinus rhythm, left bundle branch block, and inferior myocardial infarction. Based on his review of the diagnostic test results, as well as his discussion with, and evaluation of the Veteran, the VA examiner diagnosed the Veteran with having cardiomyopathy with history of congestive heart failure, status post myocardial farction, and left bundle branch block. In an addendum opinion, also dated in February 2010, the examiner noted that the echocardiogram results matched the diagnosis given, and determined that the Veteran's cardiomyopathy was more likely than not caused by his hypertension. He (the examiner) further indicated that the Veteran's diagnosis had thus changed from cardiomyopathy to "(cardiomyopathy) hypertensive heart disease." In addition to the diagnoses mentioned above, the more recent VA treatment records dated from June 2010 to August 2012 reflect that the Veteran has a history of coronary artery disease. Under the current regulatory provisions, if a veteran was exposed to an herbicide agent during active military, naval, or air service, certain diseases, to include atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery, shall be service connected if the requirements of section 3.307(a)(6) are met even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of section 3.307(d) are also satisfied. 38 C.F.R. § 3.309(e) (2017). A response to a Personnel Exchange Information System (PIES) Request for Information indicates that the Veteran served in the Republic of Vietnam from March 1969 to February 1970. As such; it is presumed that he was exposed to herbicides during his period of active service. 38 U.S.C.A. § 1116(f). Although VA treatment records reflect a history and diagnosis of coronary artery disease, the Veteran has undergone several diagnostic tests throughout the pendency of the appeal, none of which have reflected a diagnosis of coronary artery disease. Indeed, although the VA records reflect a history and diagnosis of coronary artery disease, these appear to be based more on the Veteran's reported statements, rather than on objective medical findings and test results. Furthermore, in a May 2012 letter, Dr. S. noted that the Veteran had been found to have an idiopathic cardiomyopathy that was severe, and that cardiac catheterization studies had revealed no coronary artery disease. Dr. S. further stated that although the Veteran did not have difficulty controlling high blood pressure, his ejection fraction was in the 25 to 30 percent range. According to Dr. S., "[s]ince there is no obvious etiology for the Veteran's cardiomyopathy, such as coronary disease or hypertension, one has to presume the possibility that Agent Orange could have been involved with his heart failure." Results of a June 2013 echocardiogram reflected an estimated left ventricle ejection fraction (LVEF) ranging between 35 to 40 percent and it was noted that the left ventricular systolic function was moderately reduced. There was also mild concentric left ventricular hypertrophy and the aortic valve was described as thickened and sclerotic. Other than trace mitral regurgitation and trace tricuspid regurgitation, it was noted that the study was essentially normal. Results of the August 2014 echocardiogram were similar to the June 2013 echocardiogram findings. As such, the diagnostic test findings and physical examinations of the Veteran are negative for an assessment/diagnosis of coronary artery disease, and the VA treatment records reflecting a history of coronary artery disease are based on preliminary assessments primarily based on the Veteran's reported statements rather than on physical examination findings. Although cardiomyopathy is not a recognized presumptive disorder of herbicide exposure, the possibility exists that the Veteran's cardiomyopathy is related to herbicide exposure on a direct basis. See Stefl v. Nicholson, 21 Vet. App. 120 (2007); see also Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Upon reviewing the Veteran's claims file, the VA examiner (in the November 2014 medical opinion) determined that his claimed heart disorder was less likely than not incurred in, or caused by, his claimed in-service injury, event or illness. In reaching this determination, the VA examiner noted that the Veteran began experiencing dyspnea on exertion (DOE) prior to 2008 and after being evaluated for these symptoms in 2008, he was found to have cardiomyopathy. The VA examiner also confirmed that the Veteran did not have coronary artery disease and that the only diagnosed heart disorder verified by the medical records for the Veteran was idiopathic cardiomyopathy, noting that a July 2008 left heart catheterization showed normal coronary arteries and a LVEF that was markedly depressed at 20 percent. The VA examiner also noted that the Veteran's cardiologist, Dr. S. determined that the Veteran had severe idiopathic cardiomyopathy and cardiac catheterization studies revealed no coronary artery disease. According to the VA examiner, while it is conceded that the Veteran had herbicide exposure in service, his medical records did not indicate that he had a diagnosis of a heart condition related to herbicide exposure - namely ischemic heart disease. The examiner further determined that there was no evidence in the service treatment records that the Veteran's condition began in service, as there is no documentation to reflect that he experienced symptoms consistent with this diagnosis in service, or for twenty-four years following his separation from service. In reaching this determination, the VA examiner acknowledged the Veteran's January 1983 separation examination wherein he endorsed a history of chest pain. According to the examiner, however, there is no legible report of evaluation of this complaint. In this regard, "[t]here [were] no medical findings legibly documented which reflect treatment for symptoms of chest pain in service" and "[c]hest pain is not a characteristic symptom of cardiomyopathy." As such, the examiner found that the complaints of chest pain were unlikely to have been an early manifestation, or to have led to the development of, the Veteran's current cardiac disorder. The examiner explained that symptoms more characteristic of cardiomyopathy would have been shortness of breath, dyspnea on exertion, swelling of legs and "PND." The examiner further noted that while chest pain is more characteristic of an ischemic heart disease, it has been established that the Veteran did not have ischemic heart disease, as he had normal coronary arteries even up to 2008. As such, it is highly unlikely that the chest pain reported in 1983 had any clinical connection to his current heart condition. The examiner also took into consideration the Veteran's reports of exposure to various types of chemicals while working at a paint shop and/or while working at an Aviation Hydraulic shop in service. According to the examiner, without knowing the specific types of chemicals to which the Veteran had exposure to, it would be difficult to speculate with much certainty as to the effects of these chemicals on his health. She (the examiner), however, did reference the Agency for Toxic Substances and Disease Registry (ATSDR) which indicated that most chemicals such as toluene, carbon tetrachloride and vinyl chloride (1) have not been noted to cause cardiomyopathy, and (2) cause the symptoms/condition at the time of exposure, not after exposure. In light of this finding, and given that the Veteran's symptoms developed more than twenty-four years after his exposure to these chemicals, the examiner found it less likely than not that the various types of chemicals to which the Veteran had exposure to while working at a paint shop and/or while working at an Aviation Hydraulic shop in service caused his heart condition. With regard to the May 2012 opinion issued by Dr. D.S., the VA examiner noted that the Institute of Medicine (IOM) had performed extensive reviews of the medical literature regarding the association of heart diseases and Agent Orange exposure, and the findings are that while there is medical evidence that ischemic heart disease is related to herbicide exposure, medical research is lacking to sufficiently relate idiopathic cardiomyopathy to herbicide exposure. The VA examiner also took into consideration the Veteran's reports of ongoing symptoms analogous to a heart condition since his military service, and noted that although these symptoms may be related to his current diagnosis of cardiomyopathy, there was no evidence that the Veteran has a cardiac condition related to his herbicide exposure and/or his reported exposure to various types of chemicals while working at a paint shot and/or while working at an Aviation hydraulic shop in service. In considering all of the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to service connection for a heart disorder, to include his diagnosed cardiomyopathy. In this regard, the Board acknowledges that the objective medical evidence reflects that the Veteran has been diagnosed with having idiopathic cardiomyopathy. As previously discussed, there is a lack of evidence reflecting any treatment for, or diagnosis of a heart disorder, or symptoms associated with his current cardiomyopathy during the Veteran's periods of service. Although the Veteran was seen for complaints of chest pain in February 1981, the in-service clinician determined that the etiology of these symptoms was unknown, and they may possibly be due to indigestion and tension. The Veteran also underwent an EKG in February 1981, the results of which were shown to be normal. In addition, while the January 1983 separation examination reflected the Veteran's complaints of chest pain, there is nothing in the record to show that this was an early manifestation of his later-diagnosed cardiomyopathy. Indeed, the Veteran denies experiencing any heart trouble or palpitation or pounding heart in his January 1983 medical history report The November 2014 VA examiner also took note of the Veteran's complaints of chest pain at his separation examination, but found no legible report of evaluation of this complaint. The VA examiner further explained that chest pain, while characteristic of ischemic heart disease, was not a characteristic symptom of cardiomyopathy, and as such, this complaint was not likely to have been an early manifestation of, or to have led to the development of the Veteran's current cardiac disorder. With respect to whether the Veteran's diagnosed cardiomyopathy is related to his period of service, to include his in-service herbicide exposure, and/or any other event, injury or incident in service, the Board finds the November 2014 medical opinion to be highly probative as it is based on a review of the relevant medical records, as well as the prior examination report (in February 2010) which included a discussion with the Veteran regarding his medical history, and a physical examination of the Veteran. Here, the VA examiner provided clear opinions concerning whether the Veteran's cardiomyopathy was related to his military service, to include his conceded herbicide exposure in service. The VA examiner also provided an opinion concerning the possibility of a relationship between the Veteran's exposure to various types of chemicals while working at a paint shop and/or while working at an Aviation hydraulic shop in service. In this regard, the VA examiner determined that the Veteran's current cardiomyopathy was not related to his herbicide exposure or his reported exposure to various chemicals while working at an Aviation Hydraulic shop in service, reasoning that the medical evidence did not associate or relate idiopathic cardiomyopathy to either herbicide exposure and/or to most chemicals such as toluene, carbon tetrachloride and vinyl chloride. The VA examiner based her opinion on relevant historical facts and offered a rationale for the opinions reached that is supported by the evidence of record. In reaching her negative conclusion, the examiner specifically relied on the service treatment records associated with the Veteran's periods of service which were negative for a diagnosis of a heart disorder. The VA examiner acknowledged the Veteran's complaints of chest pain at this separation examination but noted that these symptoms were not characteristic of the Veteran's subsequently diagnosed cardiomyopathy. The VA examiner also took into consideration several medical literature articles, to include research articles issued by the IOM and ATSDR, which served as the basis for the medical principles she relied upon in reaching his conclusion. The Board notes that the Veteran submitted the May 2012 letter from his private cardiologist, Dr. D.S. In this letter, Dr. D.S. determined that the Veteran had been found to have idiopathic cardiomyopathy that was severe and the cardiac catheterization studies were negative for any evidence of coronary artery disease. According to Dr. D.S., since there is no obvious etiology for the Veteran's cardiomyopathy, "one had to presume the possibility that Agent Orange could have been involved with his heart failure." 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, 1 Vet. App. at 49. Equal weight is not given to each piece of evidence contained in the record; every item of evidence does not have the same probative value. Greater weight may be placed on one physician's opinion than another's depending on factors such as reasoning employed by the physicians and whether or not (and the extent to which) they reviewed prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994). The Court has held that a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion . . . must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."); see also Miller v. Brown , 11 Vet. App. 345, 348 (1998). Here, although the Board finds that Dr. D.S., in reviewing the Veteran's medical records, being a licensed physician, and having a history of treating the Veteran, was competent to make an opinion regarding the etiology of the Veteran's cardiomyopathy, the lack of certainty and specificity in the opinion renders such opinion of low probative value when compared to the well-reasoned opinion of the November 2014 VA examiner. See Bostain v. West, 11 Vet. App. 124, 127-28 (1998), quoting Obert v. Brown, 5 Vet. App. 30, 33 (1993) (medical opinions expressed in terms of "may" also implies "may or may not" and is too speculative to establish medical nexus). It is well established that medical opinions that are speculative, general, or inconclusive in nature do not provide a sufficient basis upon which to support a claim. McLendon v. Nicholson, 20 Vet. App. 79, 85 (2006). In contrast to this opinion, the November 2014 VA medical opinion was provided in clear and definitive terms. Dr. D.S.'s opinion is further weakened by the fact that he did not reference or cite to any research materials or clinical studies in support of his opinion. This is particularly problematic where his medical determinations were contradicted by the November 2014 VA physician. The November 2014 VA physician provided a detailed explanation as to why the Veteran's cardiomyopathy was not related to his in-service herbicide exposure, his exposure to various types of chemicals while working at an Aviation hydraulic shop, or any incident, event, or injury in service, specifically noting that chest pain was not a characteristic symptom of cardiomyopathy. Therefore, the Board affords more probative value to the VA examiner's opinion in this matter. Collectively, the November 2014 and February 2010 VA opinions are based on a discussion with the Veteran regarding his medical history and current condition, a complete review of the medical records, and examination. The medical opinions are also consistent with the other evidence of record and supported by rationales. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (which holds that factors for assessing the probative value of a medical opinion are the treatment provider's access to the claims file and the thoroughness and detail of the opinion.) Thus, the Board finds that the VA examiners' opinion is entitled to more probative weight than the May 2012 medical opinion issued by Dr. D.S. To the extent the Veteran is claiming symptoms of a heart disorder present continuously since service, he is competent to do so; however, his statements are not persuasive. Indeed, although the Veteran has reported ongoing symptoms analogous to a heart condition since service, the evidence does not show that the Veteran sought treatment for his heart condition immediately following his period of service or for many years thereafter. The earliest post-service evidence of record reflecting complaints, as well as a diagnosis of, a heart condition is the April 2008 treatment report issued by Dr. D.S., nearly twenty-five years after his separation from service. The Board finds it likely that if the Veteran had significant symptoms for the many years following service, he would have sought treatment for it sooner than April 2008, and would have reported in April 2008 that he had a long history of symptoms. This is significant evidence against a finding that his symptoms were present since service and tends to show that they began many years after service. The Board acknowledges the Veteran's belief that his cardiomyopathy is related to his military service, to include his exposure to various chemicals, including herbicides, in service. The Board notes that the Veteran is competent to testify as to a condition within his knowledge and personal observation. See Barr v. Nicholson, 21 Vet. App. 303, 308-10 (2007). It is clear, however, based on a detailed review of the statements overall, that the Veteran has no actual specialized knowledge of medicine in general, or cardiovascular medicine more particularly, and that he is merely speculating as to whether his heart disorder was incurred in service. In this regard, he is not competent to diagnose this condition or symptoms or relate such to his military service, as such diagnosis and relationship are complex questions the answers to which require specialized medical knowledge and specific testing. The cause of a heart disorder manifesting relatively long after the period of service is a complex question, not a simple ones, and, under the facts of this case, not questions that can be answered by observation with ones senses. Medical expertise is required to provide competent opinions with regard to these questions. As such, the Veteran's statements to this effect are lacking in probative value. After considering the probative value of the evidence in this case, the Board finds the evidence against the Veteran's claim for service connection for a heart disorder to outweigh the evidence in favor of the claim. Specifically, the evidence is against a finding that either the in-service or nexus elements have been met for this claim. Hence, the appeal as to this must be denied. (CONTINUED ON NEXT PAGE) ORDER Entitlement to service connection for a heart disorder to include as due to in-service herbicide exposure, is denied. ____________________________________________ JAMES L. MARCH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs