Citation Nr: 18144097 Decision Date: 10/23/18 Archive Date: 10/23/18 DOCKET NO. 13-32 229 DATE: October 23, 2018 ORDER Service connection for a heart condition, to include heart murmur and coronary artery disease (CAD), is denied. FINDING OF FACT The preponderance of the evidence is against a finding that the Veteran’s heart condition had its onset in service, was manifest within a year of service, or is otherwise related to his active service. CONCLUSION OF LAW The criteria for service connection for a heart condition, to include heart murmur and CAD, have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a)-(b), (d), 3.307, 3.309(a). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Navy from January 1976 to September 1976 and in the United States Army from February 1991 to March 1991. In his November 2013 Substantive Appeal, the Veteran requested a hearing on his claim. In a September 2018 communication, he requested a cancellation of his scheduled hearing. The Board finds that the hearing request has been withdrawn. 38 C.F.R. § 20.704 (2017). The Board notes that VA treatment records were added to the claims file after issuance of the September 2013 Supplemental Statement of the Case (SSOC). However, a review of the records that were not already considered by the Regional Office (RO) (namely those from August 2013 to October 2017) do not contain relevant evidence of treatment for the claimed disability. Therefore, the Board may proceed to consider the claim. The Veteran contends that evidence of a heart murmur in service led to his current heart condition. Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). This means that the facts establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. Savage v. Gober, 10 Vet. App. 488 (1997). The provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology can be applied only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran’s January 1976 entrance examination report was silent for any cardiac condition. The August 1976 examination conducted upon his release from active duty noted a grade 2/6 systolic ejection murmur at the left second intercostal space – flow murmur, with an otherwise normal heart evaluation. No further relevant notations are contained in the service treatment records (STRs) from his second period of service and on his March 1991 service separation examination report, “no significant defects” was noted and the Veteran himself did not indicate any cardiac complaints or history. Post-service, VA records contained heart evaluations of regular rate and rhythm with no murmurs. In November 2009, an echocardiogram revealed normal left ventricular size, hyperdynamic left ventricle systolic function, and ejection fraction of 65 percent. A mild systolic ejection murmur was noted. In July 2010, another echocardiogram found normal left ventricular size, hyperdynamic left ventricle systolic function, and ejection fraction of 65 percent. Trace mitral and tricuspid regurgitation was noted. A nuclear stress test was negative with no arrhythmias. In September 2010, the Veteran was seen by VA providers with complaints of chest pain. He underwent a cardiac catheterization which was negative and determined that a previous cerebrovascular accident he had suffered did not have a cardiac source. He was diagnosed with non-obstructive CAD with normal ejection fraction. An electrocardiogram performed in January 2011 revealed normal sinus rhythm and T wave abnormality, consider lateral ischemia. All subsequent VA treatment records contained reports of regular heart rate and rhythm with no murmurs. There are several opinions of record regarding the Veteran’s claim. He underwent a VA examination in January 2012 at which time he stated to the examiner that in 1976 he felt tired all of the time and was banned from sports activity. He reported feeling occasional palpitations, with the last felt in 2009. The examiner opined that the claimed condition was at least as likely as not incurred in or caused by service because he had a murmur in the military and had a murmur at present. CAD was listed as a diagnosis but the examiner did not give an opinion regarding the etiology of the diagnosis. The Veteran submitted a private medical opinion in February 2013 which stated, “I have reviewed the patient’s VA file thoroughly and find that this patient does have chronic chest pain syndrome despite the fact that he had a normal stress test here in the office. He does have systemic hypertension and various chest pain syndromes. In my opinion, this is highly likely related to his services in the United States Service.” Another VA opinion was obtained in September 2013. The clinician stated that the murmur noted in service was a functional murmur (flow murmur) which is a heart murmur that is primarily due to physiologic conditions outside the heart, as opposed to structural defects in the heart itself. He noted that, in particular, it may be due to increased blood flow with its associated turbulence. As a result, such a murmur is not indicative of any heart pathology and may be transitory. He stated that the ensuing in-service physical examinations after August 1976 did not show that the Veteran had a persistence of a heart murmur. He determined that this provided additional evidence that the murmur heard was not related to heart valves or any cardiac structure; if it had been, then the murmur would still have been detected, which it was not. The clinician continued that the post-service trivial mitral regurgitation murmur was due to a heart valve condition, which was not the same thing as was present in service. The in-service murmur had resolved, thus current heart conditions could not be expected to arise from such a resolved condition. Moreover, he continued, the in-service resolved murmur and the post-service murmur were two different and unrelated conditions caused by two different mechanisms with no relationship to each other. He also stated that flow murmurs were not known to result in the development of CAD, since there was no underlying heart pathology to begin with. He further reported that according to the consensus of medical literature, the risk factors for CAD are age, male sex, hyperlipidemia, hypertension, diabetes mellitus, family history of myocardial infarction, obesity, cigarette consumption, chronic kidney disease, lifestyle, and psychosocial factors. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors: whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case; whether the medical expert provided a fully articulated opinion; and whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the s file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez; see also 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.”). The January 2012 VA examiner found that the claimed condition was at least as likely related to service, stating that the Veteran had a murmur in service and a murmur presently, without discussing the fact that one was a flow murmur and the other was a trivial mitral and tricuspid regurgitation murmur. Further, the examiner did not determine whether the Veteran’s currently-diagnosed CAD was related to service. The private opinion found chronic chest pain syndrome and hypertension to be related to service, without providing any rationale. There was no discussion of the Veteran’s in-service murmur, currently-diagnosed CAD, or any connection therein. Based on the foregoing, probative value of these opinions is diminished and they are less probative evidence. In contrast, the Board attaches significant probative value to the September 2013 VA opinion, and the most probative value in this case, as it is well-reasoned, detailed, consistent with other evidence of record, and included consideration of the Veteran’s pertinent medical history. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). That opinion found that the flow murmur noted in service was a separate and unrelated condition from the valvular murmur noted post-service. Further, he concluded that a flow murmur would not result in the development of CAD. The most probative evidence of record establishes that the Veteran’s CAD did not have its onset in or within a year of service and is not etiologically connected to the in-service murmur, or is otherwise related to service. He was diagnosed with non-obstructive CAD nearly twenty years after service separation. CAD was not present during service nor was there continuity of symptomatology following service. Moreover, the Veteran has many of the risk factors of CAD identified by medical literature, namely age, male sex, hyperlipidemia, hypertension, diabetes mellitus, and obesity. The Board acknowledges the Veteran’s belief that the flow murmur noted in service is connected to the post-service trivial mitral and tricuspid regurgitation murmur and non-obstructive CAD diagnosed post-service. However, he has not been shown to have the requisite specialized medical knowledge or training to render a competent opinion on such a complex medical issue which is more probative than the VA opinion. The most competent, credible, and probative medical evidence of record, the negative VA opinion, does not support service connection. As such, the Board finds that the preponderance of the evidence is against granting service connection. The benefit of the doubt doctrine is not applicable in this case as there is no doubt to be resolved. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. at 57. J. CONNOLLY Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Rachel E. Jensen, Associate Counsel