Citation Nr: 18159315 Decision Date: 12/18/18 Archive Date: 12/18/18 DOCKET NO. 11-06 671 DATE: December 18, 2018 ORDER Entitlement to service connection for a heart disability, to include subclavian steal syndrome, residuals of carotid artery bypass surgery, is denied. FINDING OF FACT A heart disability, to include subclavian steal syndrome, residuals of carotid artery bypass surgery, was not present during active service, was not manifest to a compensable degree within one year of separation from service, and is not otherwise causally related to an in-service disease or injury, including a July 1976 car accident. CONCLUSION OF LAW The criteria for entitlement to service connection for a heart disability, to include subclavian steal syndrome, residuals of carotid artery bypass surgery, have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.012, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from October 1975 to November 1976. This matter comes before the Board of Veterans’ Appeals (Board) from a November 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) which, in pertinent part, determined that new and material evidence had not been received to reopen a previously denied claim of service connection for heart problems. In a July 2017 decision, the Board reopened the claim and remanded the issue of entitlement to service connection for a heart condition, to include subclavian steal syndrome, residuals of carotid artery bypass surgery, to the RO for additional evidentiary development. Following evidentiary development, the VA Appeals Management Center (AMC) continued the previous denial in an October 2018 supplemental statement of the case (SSOC). The Veteran’s VA claims file has been returned to the Board for further appellate proceedings. Service Connection Service connection may be granted for a disability resulting from personal injury suffered or disease contracted in the line of duty. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304. 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 was incurred in service. 38 C.F.R. § 3.303(d). Service connection for certain chronic diseases, including cardiovascular-renal disease, may also be established on a presumptive basis by showing that such a 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; 38 C.F.R. §§ 3.307(a) (3), 3.309(a). In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307(a). To establish service connection under this provision, there must be: evidence of a chronic disease shown as such in service (or within an applicable presumptive period under 38 C.F.R. § 3.307), and subsequent manifestations of the same chronic disease; or if the fact of chronicity in service is not adequately supported, by evidence of continuity of symptomatology after service. 38 C.F.R. § 3.303(b) relating to continuity of symptomatology, however, can be applied only in cases involving those conditions explicitly enumerated under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The standard of proof to be applied in decisions on claims for VA benefits is set forth in 38 U.S.C. § 5107(b). Under that provision, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. Id; see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). “It is in recognition of our debt to our veterans that society has [determined that,] [b]y tradition and by statute, the benefit of the doubt belongs to the veteran.” Gilbert, 1 Vet. App. At 54. Entitlement to service connection for a heart disability, to include subclavian steal syndrome, residuals of carotid artery bypass surgery, The Veteran contends that his current heart disability, to include subclavian steal syndrome, residuals of carotid artery bypass surgery, is causally related to his active service, particularly the result of trauma he sustained during a 1976 automobile accident. Factual Background The Veteran’s service treatment records show that he was involved in a single-car accident in July 1976 while on active duty. It was noted that he had hit a telephone pole outside a lounge at 1:30 am while driving a car. On examination following the accident, he reported right sided chest pain. Physical findings included a small bruise on the breast area. The examiner indicated that no other abnormality was noted. The Veteran’s lungs exhibited good breath sounds and his heart exhibited normal sounds. There was no arrhythmia. His electrocardiogram (ECG) was normal. The assessment was minor chest trauma. In November 1976, the Veteran completed a report of medical history on which he denied having or ever having had symptoms such as shortness of breath, pain or pressure in his chest, palpitation or pounding heart, and heart trouble. He reported that he was in good health and was not taking any medications. At his November 1976 military separation medical examination, the Veteran’s heart was examined and determined to be normal. A chest X-ray was also conducted and determined to be normal. In pertinent part, the post-service record on appeal includes a September 1992radiographic report of the Veteran’s chest which determined that there was no cardiomegaly or acute cardiopulmonary process. His clinical history noted that he was a chronic smoker with a history of chronic bronchitis and alcohol abuse. In October 1998, the Veteran sought treatment for his alcohol abuse. He complained of left sided weakness, but a CAT scan was negative. The Veteran stated that he drank about a case of beer daily for three to five months and that he had seizures in 1989 during detoxification and that he was concerned of having seizures. A month later, he called an ambulance stating that he “was ready to have a seizure,” but stated that he had left sided chest pain when paramedics arrived. The medical provider noted that it was “obvious that he has been drinking today and drank last night.” In his June 1999 claim, the Veteran reported that he had a light stroke in November 1998. A July 2008, the Veteran underwent a chest X-ray secondary to his complaints of chest pain. The radiographic report noted that the Veteran’s heart, mediastinal structures, and pulmonary vasculatures were normal. The impression was that there was no active cardiopulmonary disease. VA clinical records show that in 2005, the Veteran underwent magnetic resonance angiography (MRA) of the brain and neck in connection with his complaints of steal symptoms. The results reportedly showed a right subclavian artery stenosis or occlusion. In September 2008, the Veteran was seen by a vascular surgeon who noted a diagnosis of subclavian steal syndrome. Focal severe occlusion of the right subclavian artery was found and a clinical correction was recommended. The notes indicated that the condition was identified 2 to 3 years ago, with lower blood pressure in the right arm noticed by the Veteran as far as 10 years ago. The Veteran stated that he had a history of transient ischemic attack (TIA) 5 to 10 years ago. In November 2008, the Veteran received subclavian artery bypass surgery with polytetrafluoroethylene (PTFE) graft. The November 2010 VA examiner diagnosed the Veteran with post-cerebrovascular accident (CVA) residual left upper hemiparesis. The examiner opined that the Veteran’s stroke and residuals of the Veteran’s stroke were not caused by, or were the result of, the Veteran’s in-service car accident. The rationale was that the accident was minor, with the records noting normal examination, normal EKG, no chest pain or cardiac palpitation and there being no mention of stroke. The examiner also cited to the lack of reference to stroke involvement from the accident. In July 2011, the Veteran submitted a scholarly article discussing stroke and blood clots in general terms. The article also stated that blood clots can be caused by “physical injury, inflammation, hypertension, infection, radiation and smoking.” In October 2011, the Veteran was admitted for a suspected stroke to a private medical provider. Studies ruled out a stroke. A CVA was suspected, but there was no evidence of acute infarction on the imaging. The private medical provider also noted alcohol use and stable coronary artery disease. The Veteran’s social history stated that he was a current smoker and used alcohol. His height was measured at 71 inches, weight at 94.8 kg, and his body mass index (BMI) was 29.2. The Veteran was provided diet and exercise modification education as well as smoking cessation and also blood pressure control. The September 2018 VA examiner, after reviewing the Veteran’s record, opined that the Veteran’s subclavian steal syndrome, residuals of carotid artery bypass surgery or any other diagnosed cardiac conditions were not related to the Veteran’s service. He supported his opinion by citing the minor nature of the motor vehicle accident in July 1976, and the normal examinations following the accident and at discharge. He also opined that the Veteran’s diagnosis was more likely than not proximately causally related to smoking and other health factors such as the Veteran’s hyperlipidemia. He referenced medical literature naming hypercholesterolemia, diabetes, hypertension, obesity and smoking responsible for more than half of cardiovascular mortality. Analysis Applying the facts in this case to the legal criteria set forth above, the Board finds that the preponderance of the evidence is against the claim of service connection for a heart disability, to include subclavian steal syndrome, residuals of carotid artery bypass surgery. As a preliminary matter, the Board finds that the most probative evidence establishes that a heart disability was not present during the Veteran’s active service. As set forth above, his service treatment records are negative for complaints or findings of a heart disability. Indeed, his heart was examined at service separation and was affirmatively determined to be normal. In addition, the record does not show, nor does the Veteran contend, that cardiovascular-renal disease was manifest to a compensable degree within one year following separation from active service. Although a heart disability was not shown in service or within the first post-service year, as set forth above, service connection can be diagnosed for any disease diagnosed after discharge if the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Thus, the Board has carefully reviewed the record, with particular attention to the evidence addressing the etiology of the Veteran’s current heart disability. In that regard, in September 2018, a VA examiner opined that the Veteran’s current heart disability, to include subclavian steal syndrome, is not at least as likely as not related to an in-service injury or disease, including the July 1976 car accident. The examiner provided rationale for his conclusion, noting that that the 1976 car accident was minor; that the examinations immediately after the accident were normal, including with respect to the Veteran’s heart; that there was no history of heart problems during service or at the time of discharge; and that, based on his medical knowledge, it was more likely due to the Veteran’s smoking and other health factors such as hyperlipidemia. The examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Board notes that there is no other medical opinion evidence to the contrary which suggests an alternative theory of entitlement. While the Veteran believes his subclavian steal syndrome is related to trauma sustained in the July 1976 car accident, he is not competent to provide a nexus opinion in this case. This issue is also medically complex, as it requires knowledge of the interaction between multiple organ systems in the body/interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Questions of competency notwithstanding, the Board assigns more probative weight to the conclusions of the VA examiner, who based his conclusions on the evidence of record, to include the assertions of the Veteran. The Board has also considered the evidence submitted by the Veteran that stated “endothelial damage can arise from physical injury, inflammation, hypertension, infection, radiation and smoking.” Although medical articles “can provide important support when combined with an opinion of a medical professional,” in this case, this evidence is general and does not raise a plausible causality between the Veteran’s subclavian steal syndrome and his July 1976 car accident. Mattern v. West, 12 Vet. App. 222, 228 (1999). Moreover, this evidence is not accompanied by the opinion of any medical professional, and may support the September 2018 VA examiner’s opinion as it also states “smoking” may cause “endothelial damage.” The October 2011 private medical provider also offered “smoking cessation” as part of a plan to improve the Veteran’s health, suggesting at least a correlation between the Veteran’s smoking and the Veteran’s health problems. Consequently, the Board gives more probative weight to the September 2018 VA examiner’s opinion. (Continued on the next page)   In summary, the Board concludes that the most probative evidence shows that the Veteran’s heart disability, to include subclavian steal syndrome, was not present during the Veteran’s service, was not manifest to a compensable degree within one year of separation, is not causally related to the Veteran’s active service or any incident therein. Thus, upon weighing the evidence in its entirety, the Board finds that the preponderance of the evidence is against the claim of service connection for subclavian steal syndrome, residuals of carotid artery bypass surgery or any other diagnosed cardiac conditions. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). K. Conner Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD H. Yun, Associate Counsel