Citation Nr: 1807179 Decision Date: 02/05/18 Archive Date: 02/14/18 DOCKET NO. 12-13 967 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUE Entitlement to service connection for heart condition with stent. ATTORNEY FOR THE BOARD G. A. Ong, Associate Counsel INTRODUCTION The Veteran served on active duty from May 1983 to September 1991. This matter is before the Board of Veterans' Appeals (Board) on appeal from a January 2011 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky. In May 2016, the Veteran testified before a Decision Review Officer (DRO) in a hearing held at the RO. A transcript of the hearing is associated with the claims file. This appeal was processed using the Veterans Benefits Management System (VBMS) and Virtual VA paperless claims processing systems. FINDING OF FACT A heart condition with stent was not manifest during service or within one year of separation, and is not shown to be causally or etiologically related to an in-service event, injury or disease. CONCLUSION OF LAW A heart condition with stent was not incurred in or aggravated by service. 38 U.S.C. §§ 1101, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duty to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.326(a) (2017). The Veteran has not raised any issues with the duty to notify or duty to assist. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). II. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1101, 1131; 38 C.F.R. § 3.303(a). Generally, to establish service connection a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be established for a current disability on the basis of a presumption that certain chronic diseases, to include arthritis, manifesting themselves to a certain degree within a certain time after service must have had their onset in service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309(a). Generally, the disease must have manifested to a degree of 10 percent or more within one year of service. 38 C.F.R. § 3.307(a)(3). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 CFR 3.303(b). Walker v. Shinseki, 708 F.3d 1331 (2013). VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154(a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Lay evidence cannot be determined to be not credible merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). However, the lack of contemporaneous medical evidence can be considered and weighed against a Veteran's lay statements. Id. Further, a negative inference may be drawn from the absence of complaints or treatment for an extended period. Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The Veteran contends he is entitled to service connection for a heart condition with stent. Specifically, at an RO hearing in May 2016, the Veteran asserted that chest pain complaints in service were precursors to the subsequently diagnosed 90 percent arterial blockage in the heart. After review of the entire record, the Board finds the preponderance of the evidence is against a finding of a medical nexus between active service and the Veteran's heart condition disability. Service treatment records show that the Veteran sought treatment for chest pain symptoms while in-service in May 1989 and August 1989. In April 1990, the Veteran endorsed chest pain radiating into his left arm and dizziness. The Veteran underwent an EKG that was reportedly abnormal but the evaluator indicated that a clinical correlation was necessary. The Veteran reported that he was able to run one and one-half miles twice per week without problems. Normal findings were reported on a subsequent EKG performed in November 1990. In a November 1900 physical examination, the examiner noted no heart abnormalities. In a dental patient health screening the same month, the Veteran denied any heart disease or condition and reported that he was in excellent health. The record reflects the Veteran has a current diagnosis of coronary artery disease. A post-service June 1998 chest x-ray was assessed as a negative examination of the heart and lungs. Upon referral, the Veteran presented to the Cardiovascular Associates in June 1998 for a consultative evaluation. The Veteran described his chest discomfort as an occasional sharp pain but with no symptoms of exertional angina or classic angina symptoms, and further denied dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, edema, dizziness, or syncope. An echocardiogram and electrocardiogram (EKG) yielded normal functioning, while a Holter monitor noted frequent single PVCs and occasional isolated supraventricular beats with no complex or sustained ectopy. Post-service private outpatient treatment records further contain EKGs performed in July 2005 and June 2007 that were assessed as normal. Subsequently in February 2009, the Veteran underwent a coronary angiography with stenting, left heart catheterization, and left ventriculography. The left ventricular ejection fraction (LVEF) was measured at 60 percent. In a follow-up examination in December 2009, the attending physician noted that the Veteran was doing well with no chest pain or shortness of breath and cited a normal electrocardiogram. In August 2010, the Veteran's treating cardiologist submitted a letter on behalf of the Veteran. The cardiologist noted the Veteran initially presented to him for treatment for chest discomfort in February 2009. It was reported the Veteran subsequently underwent cardiac catheterization which revealed a critical lesion in his proximal left anterior descending (LAD) artery. The cardiologist indicated the Veteran underwent an angioplasty and drug eluting stent implantation, and had done well since then. The cardiologist opined that the condition had gone on for about five months prior to his angioplasty but that it was "hard to say" if the Veteran "could not have had some disease prior to that." The cardiologist further opined that it was a "fairly" acute presentation. The record reflects the Veteran was afforded a VA heart examination in June 2011. A VA nurse practitioner (NP) noted a review of the claims file and referenced the episodes of chest pain in service and the Veteran's coronary artery disease and his angioplasty with stent placement in 2009. During the examination, the Veteran underwent a series of diagnostic testing. The VA examiner reported that a stress test yielded a metabolic equivalent (MET) level of 10. Although an EKG was reportedly abnormal with nonspecific T-wave abnormalities, an X-ray of the chest identified no cardiac or pulmonary abnormalities. The NP first noted that the current CAD and residuals of a stent was less likely than not cause by chest pain in service. Then in a rationale, the NP noted, "I believe that the veteran's in service chest pain was (sic) likely related to his heart rhythm disturbance noted by cardiology consult 6/98-PVC s with SVT." However, the NP continued, "There are a wide variety of circumstances that could have caused this phenomenon. There is no concrete evidence that CAD existed while in service. I believe that the veteran s cardiologist felt that his CAD was a semiacute process and documented such in his letter. The veteran s CAD is far more likely related to his poorly controlled Dm type 2 than any other single factor. There is no documentation for significant C/O or TX for chest pain from discharge in 1991 to 2009 which again favors a more acute process." Notwithstanding the apparent inconsistency within the statement, the Board finds that the NP's rationale is that that the current CAD did not first manifest in service and was more likely associated with diabetes. The record reflects that the Veteran's treating cardiologist submitted a subsequent letter in July 2011. The cardiologist, upon review of service treatment records, stated that the Veteran was evaluated with an ECG, Holter monitors, or echocardiograms, but never underwent a stress test or cardiac catheterization. The cardiologist opined that it is possible that the Veteran "may" have had some of his coronary disease prior to his 2009 visit. Regarding the letters submitted by the Veteran's treating cardiologist, the use of the words "possible," "may," or "can be" make a doctor's opinion speculative in nature. See Bostain v. West, 11 Vet. App. 124, 127-28 (1998) (quoting Obert v. Brown, 5 Vet. App. 30, 33 (1993)) (medical opinion expressed in terms of "may" also implies "may or may not" and is too speculative to establish medical nexus). See also Warren v. Brown, 6 Vet. App. 4, 6 (1993) (doctor's statement framed in terms such as "could have been" is not probative); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992) ("may or may not" language by physician is too speculative). The opinions are speculative in nature and as such are not probative. It is well established that medical opinions that are speculative, general, or inconclusive in nature do not provide a sufficient basis upon which to support a claim. McLendon v. Nicholson, 20 Vet. App. 79, 85 (2006). The VA examiner opined in a March 2012 Disability Benefits Questionnaire that the heart condition with stent was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The VA physician opined that the Veteran's in-service chest pain was likely related to the heart rhythm disturbance noted in the June 1998 consultative cardiology visit. The VA examiner further opined that there is no concrete evidence that coronary artery disease existed while in service, and stated there is no documentation for significant complaints of or treatment for chest pain from the 1991 discharge to 2009, which favors the conclusion that the reported chest pains were an acute process. The physician noted, "The veteran s CAD is far more likely related to his poorly controlled Dm type 2 than any other single factor. There is no documentation for significant C/O or TX for chest pain from discharge in 1991 to 2009 which again favors a more acute process." The physician noted normal EKGs from 1989 to 2008 with no evidence of changes associated with coronary artery disease were further cited by the VA examiner. Based upon the significant single vessel blockage identified about 18 years after discharge, the VA physician opined that the assertion that coronary artery disease was present in 1991 at the time of discharge is pure speculation by the Veteran's treating physicians and reiterated that there is no medical evidence to suggest that the lesion existed during service. An addendum VA heart opinion was obtained in October 2017. The VA physician opined that it is less likely as not that the Veteran's heart condition with stent was incurred in or caused by an illness in service. The VA examiner opined that there is no relation to service at all. The VA examiner referenced service treatment notes that show reports of chest pain, but further highlighted the normal EKGs and that the Veteran was never diagnosed with a heart condition. The VA examiner stated that the Veteran separated from service in 1991 and was not diagnosed until 18 years later in February 2009 with coronary artery disease requiring a stent. The VA examiner stated that the medical history taken prior to the stent placement reflects the Veteran had chest pain for about 2 weeks prior. The VA examiner opined that the chest pain in 2009 would not be the same as that in 1991. The June 2011 and October 2017 VA examiners appropriately considered and addressed the Veteran's contentions, reviewed the claims file in conjunction with their examination reports, and provided sufficient supporting rationales for their respective opinions. The June 2011 VA examiner also conducted a thorough medical examination of the Veteran, including diagnostic testing. Although the opinions of the Veteran's treating cardiologist are speculative in nature, read together with the reports of the VA examiners, the record does not show a positive nexus. Rather, as opined by the treating cardiologist in August 2010, the Veteran's chest discomfort in February 2009 that resulted in an angioplasty was an acute presentation of symptoms. Therefore, the reports of the VA examiners are consistent with the evidence of record, are credible, and entitled to significant probative weight. At the hearing before the DRO in May 2016, the Veteran asserted that the chest pain complaints in service were precursors to the subsequently diagnosed 90 percent arterial blockage in the heart. While the Veteran may be competent to report the manifestation of symptoms of chest pain, he is not competent to provide medical opinions regarding the causes or aggravating factors of coronary artery disease. As the Veteran is not shown to have appropriate medical training and expertise, he is not competent to render probative (i.e., persuasive) opinions on medical matters. See Jandreau, 492 F.3d at 1376-77; Bostain v. West, 11 Vet. App. 124, 127 (1998); Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"). Therefore, his lay assertions in this regard have no probative value. Turning to the presumption in favor of chronic diseases and continuity of symptomatology, the Veteran has been diagnosed with coronary artery disease and is therefore considered a chronic disease for VA purposes. 38 C.F.R. § 3.309(a). As such, both theories are potentially applicable in this case. Walker, 708 F.3d 1331; 38 C.F.R. §§ 3.303(b), 3.307, 3.309. However as discussed above, the medical evidence does not show that the Veteran's coronary artery disease manifested to a sufficient degree in-service to identify the disease entity or within the first post-service year. In sum, the competent and credible evidence of record does not demonstrate that the Veteran's heart condition arose in service or is otherwise related to service. As there is no competent nexus opinion underlying the claim, service connection for the disability is not warranted. 38 C.F.R. §§ 3.303, 3.310. Since the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990); 38 C.F.R. § 3.102. For these reasons, the claim is denied. ORDER Entitlement to service connection for heart condition with stent is denied. ____________________________________________ J. W. FRANCIS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs