Citation Nr: 18154830 Decision Date: 11/30/18 Archive Date: 11/30/18 DOCKET NO. 12-27 108A DATE: November 30, 2018 ORDER Entitlement to service connection for sick sinus syndrome (SSS), to include as secondary to exposure to herbicide agents, and including as secondary to service-connected diabetes mellitus, posttraumatic stress disorder (PTSD), is denied. FINDINGS OF FACT 1. The Veteran served in the Republic of Vietnam during the Vietnam era and exposure to herbicides agents for that period of service is presumed. 2. The Veteran is not diagnosed with ischemic heart disease, including coronary artery disease. 3. The Veteran’s SSS is not causally or etiologically related to his active duty service, to include conceded exposure to herbicide agents. 4. The Veteran’s SSS was not caused or aggravated by his service-connected diabetes mellitus or PTSD. CONCLUSION OF LAW The criteria to establish service connection for SSS, to include as secondary to exposure to herbicide agents, and including as secondary to service-connected diabetes mellitus and PTSD, are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 5107 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty in the United States Army from June 1968 to June 1971, and from November 1974 to November 1978. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from September 2011 rating decision by the Regional Office (RO) of the Department of Veterans Affairs’ (VA). This matter was remanded by the Board in December 2015, August 2017 and February 2018, to the Agency of Original Jurisdiction(AOJ) for additional medical evidence. The case has since returned to the Board for further appellate consideration. Service Connection Legal Criteria Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303(a) (2017). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease incurred in service. 38 C.F.R. § 3.303(d) (2017). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In addition, a chronic disease will be presumed to have been incurred in or aggravated by service if it had become manifest to a degree of 10 percent or more within one year of a veteran's separation from service. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Only certain chronic diseases that are listed under 38 C.F.R. § 3.309(a) (2017) are entitled to the presumptive service connection provisions of 38 C.F.R. § 3.303(b). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Pursuant to the authority granted by the Agent Orange Act of 1991, VA may determine that a presumption of service connection based on exposure to herbicides used in Vietnam is warranted for conditions that VA has found to have a statistically significant association with such exposure. As such, VA has determined that a statistically significant association exists between exposure to herbicides and subsequent development of ischemic heart disease, as relevant here. See 38 C.F.R. § 3.309(e). For purposes of 38 C.F.R. § 3.309(e), the term "ischemic heart disease" includes acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (CAD) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina. However, "ischemic heart disease" does not include hypertension or peripheral manifestations of arteriosclerosis such as peripheral vascular disease or stroke, or any other condition that does not qualify within the generally accepted medical definition of ischemic heart disease. 38 C.F.R. § 3.309. VA's Secretary has determined that a presumption of service connection based on exposure to herbicides used in the Republic of Vietnam during the Vietnam era is not warranted for any condition for which the Secretary has not specifically determined a presumption of service connection is warranted. See 68 Fed. Reg. 27,630 (May 20, 2003). In this regard, the Board observes that VA has issued several notices in which it was determined that a presumption of service connection based upon exposure to herbicides used in Vietnam should not be extended to certain specific disorders, based upon extensive scientific research. See Notices, 68 Fed. Reg. 27,630 -41 (2003); 64 Fed. Reg. 59,232 -243 (1999); 61 Fed. Reg. 57,586 -589 (1996). However, the United States Court of Appeals for the Federal Circuit (Federal Circuit) has determined that an appellant is not precluded from establishing service connection with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994); Ramey v. Brown, 9 Vet. App. 40, 44 (1996), aff'd sub nom, Ramey v. Gober, 120 F.3d 1239 (Fed. Cir. 1997), cert. denied, 118 S. Ct. 1171 (1998). The United States Court of Appeals for Veterans Claims (Court) has specifically held that the provisions of Combee are applicable in cases involving Agent Orange exposure. McCartt v. West, 12 Vet. App. 164, 167 (1999). Service connection may also be established on a secondary basis for a disability that is shown to be proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Id.; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). Any increase in the severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disability, will be itself service-connected. 38 C.F.R. § 3.310(b). When considering whether lay evidence is competent, the Board must determine, on a case-by-case basis, whether a veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. See Layno, 6 Vet. App. 465, 469. Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303 (2007). Lay evidence may establish a diagnosis of a simple medical disability, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau, 492 F.3d 1372, 1377. Reasonable doubt concerning any matter material to the determination is resolved in the Veteran's favor. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Service Connection Analysis The Veteran asserts that his SSS was caused by his exposure to herbicide agents or alternatively caused or aggravated by his service-connected diabetes mellitus and/or service-connected PTSD. The Veteran’s service treatment records are silent as to any complaints, treatment, or diagnosis of SSS or any reports of symptoms related to the heart. Notably, his October 1978, separation examination showed that he had a normal heart and cardiovascular system. Post-service treatment records show that the Veteran was hypertensive since 1999, diagnosed with diabetes mellitus nephropathy in 2002, and PTSD in 2005. In his December 2011 notice of disagreement, the Veteran stated that he believed he had CAD. In August 2014, the Veteran underwent a VA compensation examination. The internist/pulmonologist who conducted the examination opined that the Veteran’s electrocardiogram and echocardiogram examination’s findings were not consistent with the coronary artery disease/ischemic heart disease listed under 3.309. The examiner also conducted a dobutamine stress echocardiogram which came back negative for ischemia. Based on these examinations and a review of the file, the examiner concluded that the Veteran’s SSS is not CAD or an ischemic heart disease. Given that the August 2014 VA examiner did not address whether the Veteran’s SSS was aggravated by his current service-connected diabetes mellitus and PTSD, the claim was remanded by the Board. In a February 2017 addendum opinion, the VA examiner stated that it was possible to determine the baseline of severity for the Veteran’s SSS, using available medical evidence. The examiner then explained that although malfunction of the sinus node automaticity may be caused by chronic exposure to hyperinsulinemia secondary to insulin resistance in diabetes mellitus patients, the Veteran’s SSS preceded the onset of his service-connected diabetes mellitus, type 2. The examiner further explained that the Veteran’s service-connected lower back condition was not a risk factor for SSS. When reviewing the Veteran’s medical records, the examiner noted his past symptoms, such as chest pains, palpitations, shortness of breath and intermittent dizziness with several episodes of syncope in 1996. However, the examiner explained that there was no evidence of aggravation or worsening following the Veteran’s diagnosis’ for PTSD and diabetes mellitus as he has denied the continuous recurrence of such symptoms. The examiner further reasoned that there was no aggravation of the Veteran’s SSS despite his having had poorly-controlled diabetes and progressive neuropathic pains as the years passed. Regarding PTSD, the examiner explained that it was independently associated with increased risk for coronary artery disease. However, the Veteran did not have a diagnosis of coronary artery disease as evidenced by a March 2014 Dobutamine stress echocardiogram and an August 2014 2D echocardiogram. The examiner ultimately determined that the current severity of the Veteran’s SSS had not progressed beyond its baseline and was not aggravated by his service-connected diabetes mellitus and PTSD. In a May 2018 addendum, the VA examiner opined that the Veteran’s SSS was less likely than not incurred in or caused by the presumed exposure to agent orange herbicide agents during service. The examiner reasoned that there is a lack of medical evidence to support SSS was caused by or can be caused by exposure to agent orange herbicide agents. The examiner further opined that based on a review of the Veteran’s claims file, to include his service treatment records, there were no symptoms during service or within a year of service that were relevant to the current diagnosis of SSS. The examiner concluded that the Veteran’s condition of SSS did not have its onset in-service, within one year following service discharge, and was otherwise unrelated to the Veteran’s military service. Discussion The Veteran’s SSS, as diagnosed by a private physician, is a current disability, thereby satisfying the first element of the claim for service connection. Moreover, based on the Veteran’s service in the Republic of Vietnam, the Board finds that he is presumed to have been exposed to herbicide agents. See DD 214 Certificate of Release from Active Duty. However, SSS is not among the conditions subject to presumptive service connection as a disease associated with exposure to herbicide agents. See 38 C.F.R. § 3.309(e). Moreover, despite the Veteran’s assertion, SSS is not a type of ischemic heart disease, to include coronary artery disease, as confirmed by the August 2014 VA examiner. The Board finds the VA medical opinion to be thorough, complete, and sufficient upon which to base a decision with respect to the Veteran’s claim. See Stefl v. Nicholson, 21 Vet. App. 120, 123-24 (2007) (finding that an adequate opinion is one that is based upon consideration of the Veteran’s prior medical history and examinations, describes the disability in sufficient detail, and includes a conclusion supported by an analysis that the Board can consider and weigh against contrary opinions). Nevertheless, the Veteran is not precluded from establishing service connection for SSS with proof of direct causation. However, based on a careful review of all the evidence, both lay and medical, the Board finds that service connection is also not warranted on direct or secondary bases. There is no competent evidence of a nexus between the Veteran’s current SSS and his military service, to include herbicide agent exposure, and no competent evidence of a nexus between his SSS and a service-connected disability. These findings are based on the VA medical opinions rendered in February 2017 and May 2018. Collectively, the examiners reasoned that there is no in-service evidence of SSS complaints, symptoms, treatment, or diagnosis; no evidence of a relationship between SSS and herbicide agent exposure, and no evidence of the Veteran’s SSS having been caused or aggravated by his service-connected disabilities. The Board finds these VA medical opinions to be highly probative because they are factually accurate and reasonably sound. Indeed, prior to rendering the opinions, the VA examiners reviewed the Veteran’s claims file and the relevant evidence. Each of the medical opinions provided a reasoning after reviewing the Veteran’s own statements and medical history. Moreover, although the Veteran believes that he is diagnosed with coronary artery disease, he is not shown, under the facts of this case, to possess the necessary knowledge and expertise to diagnose a complex medical condition such as heart disease. Thus, while the Veteran is competent to report his observable symptoms, to include intermittent dizziness and shortness of breath, he is not competent to diagnosis a heart disability or relate his current SSS to his military service or his service-connected disabilities, as such requires the education, training and expertise of a medical professional. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). In sum, for the reasons and bases expressed above, the Board finds that the weight of the evidence does not support an award of service connection for SSS. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine does not apply. 38 U.S.C. § 5107 (2012); 38 C.F.R. §§ 4.3, 4.7 (2018). S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD D. Wagner, Counsel