Citation Nr: 18143609 Decision Date: 10/19/18 Archive Date: 10/19/18 DOCKET NO. 14-38 232 DATE: October 19, 2018 ORDER Service connection for bradycardia and atrial fibrillation, to include as a result of exposure to herbicide agents, and to include as secondary to posttraumatic stress disorder (PTSD) with alcohol abuse, is granted. FINDING OF FACT The Veteran’s atrial fibrillation and bradycardia are etiologically related to his presumed in-service exposure to herbicide agents and/or to his service-connected PTSD with alcohol abuse. CONCLUSION OF LAW The criteria for service connection for atrial fibrillation and bradycardia have been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active military service from January 1970 to February 1972, including service in the Republic of Vietnam. 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 military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection requires competent evidence showing: (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. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection may also be established on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disability. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a disability which is aggravated by a service-connected disability. In order to prevail on the issue of secondary service connection, the record must show (1) evidence of a current disability; (2) evidence of a service connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509 (1998). Further, a veteran who served in Vietnam during the Vietnam Era is presumed to have been exposed to Agent Orange. 38 U.S.C. § 1116; 38 C.F.R. § 3.307. Certain enumerated chronic diseases associated with exposure to herbicide agents (Agent Orange) may be service-connected on a presumptive basis as due to exposure to herbicides. 38 C.F.R. § 3.309 (e). Of note, ischemic heart disease (IHD) is a disease that VA regulations include on the presumptive list. No other heart disease or condition is on the list. The Veteran is seeking service connection for atrial fibrillation (AF) with bradycardia. He was diagnosed with AF with bradycardia in 2006, and has asserted that his heart condition was caused by his presumed exposure to herbicide agents such as Agent Orange while in service. Because atrial fibrillation is not a condition which is presumptively associated with herbicide exposure, service connection is not warranted on a presumptive basis. However, as discussed further below, other theories of service connection are warranted for the Veteran’s claim. In March 2012, a VA examiner stated that, per the medical literature, enough studies have not been done to support a causal relationship between Agent Orange and AF. Since that time, the Veteran submitted numerous pieces of medical literature that he contended supported such a relationship. He also submitted a letter from his treating physician, Dr. K.K., who reviewed some of the literature provided by the Veteran and provided an opinion on a multi-step relationship between Agent Orange and cardiac changes. The Veteran is also service-connected for PTSD with alcohol abuse. A VA examiner diagnosed this condition in a March 2012 PTSD examination. The Veteran’s representative also asserted that his AF with bradycardia could be secondary to his PTSD with alcohol abuse. In May 2018, the Board requested a VHA specialist opinion from a cardiologist for clarity on the issue of whether the Veteran’s AF condition was etiologically related to his presumed in-service Agent Orange exposure or to his service-connected PTSD with alcohol abuse. See 38 C.F.R. § 20.901 (a). Such opinion was rendered in October 2018 by Dr. C.P., the Director of cardiac electrophysiology at the San Francisco VA Medical Center. Dr. C.P. concluded that it was at least as likely as not that exposure to herbicide agents during the Veteran’s active service contributed to his AF, and that it was at least as likely as not that the Veteran’s AF was caused by his PTSD and alcohol abuse. In rendering these opinion, Dr. C.P. provided a detailed review of the related medical literature and the relevant portions of the Veteran’s medical history, and determined that there was medical evidence and literature to support the Veteran’s contentions. Because Dr. C.P. is a cardiologist, she is presumed to have the education and training commensurate with such a position, as she is an expert in cardiology. Regarding a medical nexus between herbicide agent exposure and the Veteran’s AF, Dr. C.P. explained how a confluence of risk factors are present in those diagnosed with AF, and are presumed to be involved in AF development. This particular Veteran, she noted, has risk factors for AF, including a history of hypertension and alcohol use. She then described the “mounting evidence” which suggests that herbicide agents increase the likelihood of hypertension and cardiac remodeling, leading to a chain of events that eventually can cause AF development. Regarding a causal link between the Veteran’s service-connected PTSD and alcohol abuse and the Veteran’s AF, Dr. C.P. noted that alcohol use is a well-established risk factor for AF. She also reported that PTSD impacts the body in specific ways which increase the incidence of other well-established AF risk factors. In light of the above, the Board finds that the elements of service connection have been met and service connection is warranted for the Veteran’s atrial fibrillation with bradycardia. MATTHEW W. BLACKWELDER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. Davidoski, Associate Counsel