Citation Nr: 18156119 Decision Date: 12/07/18 Archive Date: 12/07/18 DOCKET NO. 15-38 125 DATE: December 7, 2018 ORDER Service connection for congestive heart failure is granted. FINDING OF FACT The evidence is at least evenly balanced as to whether the Veteran’s congestive heart failure is related to his in-service CONCLUSION OF LAW The criteria for service connection for congestive heart failure have been met. 38 U.S.C. §§ 1101, 1110, 5107 (2012); 38 C.F.R. §§3.102, 3.303, 3.304 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from July 1967 to July 1970. This matter comes before the Board of Veterans’ Appeals (Board) from an August 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama, which denied the Veteran’s claims for service connection for damage to the heart. In November 2018, the Veteran testified at a travel Board hearing conducted before the undersigned Veterans Law Judge. A transcript of that hearing is not of record, but one is not necessary for a decision on the claim. Service connection for congestive heart failure is granted. Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, or air service. 38 U.S.C. §§ 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In a November 2012 statement in support of the claim, the Veteran indicated he had a heart attack in January 2011. Private medical treatment records from June 2012 diagnosed the Veteran with heart failure. Moreover, private medical treatment records, in conjunction with the Veteran’s release of information records, show that the Veteran underwent cardiac surgery in January 2011 and coronary stent placement in May 2012. The Veteran’s release of information records state he has been wearing an implantable cardioverter defibrillator (ICD) since August 2012. More recently, July 2013 private medical records diagnose the Veteran with mild mitral regurgitation and mild tricuspid regurgitation. As discussed below, private medical opinions reflect a diagnosis of congestive heart failure. Therefore, the Veteran has satisfied the current disability element. According to the Veteran’s December 1967 service treatment records (STRs), the Veteran was unloading boxes when the skin around his right index finger broke down. The Veteran was treated for a paronychia nail infection, an infection that tested positive for BETA streptococcus. The Veteran tested positive for streptococcus and was prescribed a 10-day course of oral Penicillin. As explained below, this satisfied the in-service disease element of this service connection claim. The Veteran submitted online articles that explained the relationship between streptococcus, rheumatic fever, and mitral valve regurgitation. Among these articles was a University of South Carolina article stating that streptococcus has “serious complications” including rheumatic fever. In addition, according to a MamasHealth article, rheumatic fever causes rheumatic heart disease which can damage heart valves. When heart valves are damaged and do not close properly, this is known as mitral valve regurgitation or mitral valve prolapse, according to the “Tricuspid Valve Regurgitation” article from Heart.org and “What is Mitral Valve Prolapse” article from the National Heart Lung and Blood Institute. The articles submitted by the Veteran reflect a causal relationship between streptococcus and heart damage, showing how streptococcus can lead to rheumatic fever and rheumatic fever often leads to heart valve damage and regurgitation. For the following reasons, the evidence supports a causal relationship between the current heart damage and the in-service streptococcus. There are two positive medical opinions on the matter. In April 2017, based on her review of the Veteran’s records, a private physician, noting that the Veteran had severe congestive heart failure, opined that it was possible that the Veteran had rheumatic fever in service that caused his current heart problems. She based her opinion on the fact that, “[w]hen reading his records from the original [index finger] infection, he had multiple symptoms of [r]heumatic [f]ever including skin changes, edema, migratory joint pain and selling….” The doctor also explained that “cardiac changes sometimes do not happen until later in life,” thus explaining why the Veteran’s heart disorders were not diagnosed until many years after service. Similarly, in March 2018, another private physician noted the Veteran’s congestive heart failure and opined that the Veteran likely experienced rheumatic fever in service, a fever that can lead to cardiac damage. The physician explained that, “[b]ased on the review of records it is possible he could have had [r]heumatic [f]ever since permanent since cardiac damage does not occur until decades after the original infection/illness.” Both the April 2017 and March 2018 medical opinions, when combined with the submitted medical literature, provide evidence that is at least evenly balanced as to whether the current congestive heart failure is related to the in-service disease. See Sacks v. West, 11 Vet. App. 314, 317 (1998) (medical article and treatise evidence “can provide important support when combined with an opinion of a medical professional”). The fact that the medical opinions use the words “could” and “possible” respectively, does not make these opinions inadequate. See Hogan v. Peake, 544 F.3d 1295, 1297-98 (Fed. Cir. 2008) (even if flawed because stated uncertainly, an opinion from a licensed counselor regarding the etiology of a claimant’s psychological disorder must be considered as “evidence” of whether the disorder was incurred in service). Both medical opinions are probative as they were predicated on a review of the record, considered all pertinent evidence, and included clear conclusions with supporting data as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). There is no contrary opinion in the evidence of record. (Continued on the next page)   Based on the foregoing, the Board finds that the evidence is at least evenly balanced as to whether the Veteran’s current congestive heart failure was incurred in service. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for congestive heart failure is warranted. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. Jonathan Hager Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Lopez, Law Clerk