Citation Nr: 18160181 Decision Date: 12/27/18 Archive Date: 12/26/18 DOCKET NO. 17-36 319 DATE: December 27, 2018 ORDER Entitlement to service connection for atrial fibrillation and cardiac arrhythmias, secondary to service-connected hypertensive heart disease on a causation basis, is granted. Entitlement to service connection for hypertensive nephrosclerosis and chronic kidney disease, secondary to service-connected hypertension on a causation basis, is granted. FINDINGS OF FACT 1. The Veteran’s atrial fibrillation and cardiac arrhythmias are caused by service-connected hypertensive heart disease. 2. The evidence is at least evenly balanced as to whether the Veteran’s hypertensive nephrosclerosis and chronic kidney disease are caused by service-connected hypertension. CONCLUSIONS OF LAW 1. The criteria for service connection for atrial fibrillation and cardiac arrhythmias, as secondary to service-connected hypertensive heart disease on a causation basis, are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 2. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for hypertensive nephrosclerosis and chronic kidney disease, as secondary to service-connected hypertension on a causation basis, are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1961 to September 1965. These matters come before the Board of Veterans’ Appeals (Board) from a June 2015 rating decision. Entitlement to service connection for atrial fibrillation, cardiac arrhythmias, hypertensive nephrosclerosis, and chronic kidney disease, secondary to service-connected disabilities 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, 1131; 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). Service connection is also provided for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). 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. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. The Veteran contends that he has current cardiac disability other than hypertensive heart disease and current kidney disability, and that these disabilities are associated with his service-connected disabilities. The Board finds, for the following reasons, that the Veteran has current diagnoses of atrial fibrillation, cardiac arrhythmias, hypertensive nephrosclerosis, and chronic kidney disease, that the atrial fibrillation and cardiac arrhythmias are caused by service-connected hypertensive heart disease, and that the evidence is at least evenly balanced as to whether the hypertensive nephrosclerosis and chronic kidney disease are caused by service-connected hypertension. A June 2015 VA examination report and an August 2015 letter from R. Nanda, M.D. show the Veteran has current diagnoses of atrial fibrillation, cardiac arrhythmias, hypertensive nephrosclerosis, and chronic kidney disease. As for the etiology of these disabilities, the physician who conducted the June 2015 VA examination opined, in pertinent part, that the Veteran’s kidney disability was not likely (“less likely as not”/“less than 50/50 probability”) proximately due to or the result of service-connected hypertension. The rationale was that the Veteran’s mild chronic renal disease was likely secondary to his history of kidney cancer requiring nephrectomy and that he was 75 years old with multiple medical problems. In her August 2015 letter, Dr. Nanda reported that she was the Veteran’s treatment provider and that he had a history of hypertension for more than 20 years. She explained that the Veteran subsequently developed “complications of hypertensive nephrosclerosis causing chronic kidney disease and hypertensive heart disease causing arrhythmias and atrial fibrillation.” There was no further explanation or rationale provided for this opinion. The June 2015 opinion is of somewhat limited probative value because the examiner did not provide a specific explanation for why the Veteran’s kidney disability was more likely due to his history of kidney cancer and nephrectomy, as opposed to hypertension. In addition, the examiner did not have the opportunity to comment on the potential significance of medical literature that was identified by the Veteran in a statement that accompanies his July 2017 substantive appeal (VA Form 9). Specifically, the Veteran referenced information in the Merck Manual which indicated that the causes of chronic kidney failure include high blood pressure. As for Dr. Nanda’s August 2015 opinion, the Board acknowledges that this also is not accompanied by any detailed explanation or rationale. Nevertheless, Dr. Nanda essentially concluded based upon her treatment of the Veteran and consideration of his history that the current atrial fibrillation and cardiac arrhythmias were caused by his service-connected hypertensive heart disease and that the current hypertensive nephrosclerosis, and chronic kidney disease were caused by his service-connected hypertension. Dr. Nanda’s opinion is thus entitled to some probative weight. See Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (the fact that the rationale provided by an examiner “did not explicitly lay out the examiner’s journey from the facts to a conclusion,” did not render the examination inadequate); Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012) (medical reports must be read as a whole and in the context of the evidence of record). In light of Dr. Nanda’s August 2015 opinion, the Board finds that the preponderance of the evidence reflects that the Veteran has current atrial fibrillation and cardiac arrhythmias that are caused by his service-connected hypertensive heart disease. There is no medical opinion that is specifically contrary to this conclusion. Hence, the criteria for service connection for the currently diagnosed atrial fibrillation and cardiac arrhythmias, as secondary to service-connected hypertensive heart disease on a causation basis, have been met. Moreover, in light of the June and August 2015 opinions described above, the Board finds that the evidence is at least evenly balanced as to whether the evidence indicates that the current hypertensive nephrosclerosis and chronic kidney disease are caused by the Veteran’s service-connected hypertension. 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 the currently diagnosed hypertensive nephrosclerosis and chronic kidney disease, as secondary to service-connected hypertension on a causation basis, is also warranted. Jonathan Hager Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Elwood, Counsel