Citation Nr: 20021535 Decision Date: 03/26/20 Archive Date: 03/26/20 DOCKET NO. 16-50 623 DATE: March 26, 2020 ORDER Service connection for coronary artery disease (CAD) is granted. FINDING OF FACT The weight of the competent and probative evidence is at least in equipoise as to whether a pre-existing heart disorder increased in severity during the Veteran’s period of service and there is not clear and unmistakable evidence that the increase in severity during service was due to the natural progression of the condition. CONCLUSION OF LAW The criteria for entitlement to service connection for CAD have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.306. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from May 1982 to February 1989, November 1990 to May 1991, and October 2001 to October 2002. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a June 2013 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In February 2020, the Veteran testified at a Board hearing. A transcript of the hearing has been associated with the virtual file. Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). As a general matter, establishing service connection requires competent evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); 38 C.F.R. § 3.303. A veteran will be considered to have been in sound condition when examined, accepted and enrolled for service except as to defects, infirmities, or disorders noted at the time, or where evidence or medical judgment establishes that an injury or disease preexisted service. 38 U.S.C. § 1132; 38 C.F.R. § 3.304(b). When a defect, infirmity, or disorder is noted on the enlistment examination, the presumption of soundness never attaches, and the only benefits that can be awarded are for aggravation pursuant to 38 U.S.C. § 1153 and 38 C.F.R. § 3.306. See Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). In such claims, the evidence of record must simply show that there was an increase in disability during service to trigger the presumption of aggravation. See id.; Jensen v. Brown, 19 F.3d 1413, 1417 (Fed. Cir. 1994). “If the presumption of aggravation under [S]ection 1153 arises, the burden shifts to the government to show a lack of aggravation by establishing ‘that the increase in disability is due to the natural progress of the disease.’“ Wagner, 370 F.3d at 1096 (citing 38 U.S.C. § 1153 ). This requires the government to show by clear and unmistakable evidence that any increase in disability was due to the natural progress of the condition. See Cotant v. Principi, 17 Vet. App. 116, 130-32 (2003); see also 38 C.F.R. § 3.306(b). In relevant part, 38 U.S.C. § 1154(a) requires that VA give “due consideration” to “all pertinent medical and lay evidence” in evaluating a claim for disability benefits. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 57-58 (1990). The Veteran is competent to report symptoms and experiences observable by his senses. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); 38 C.F.R. § 3.159(a). The Veteran contends that a first-degree AV block was indicated through an ECG in 1996, prior to service, and active duty aggravated the condition resulting in current CAD. Specifically, the Veteran stated the stress of deployment and his MOS accelerated his preexisting heart condition beyond its normal progression. See October 2016, VA Form 9; October 2016, Correspondence; February 2020, Hearing transcript. After review of the record, the Board finds that the criteria for service connection for CAD have been met. The record contains a competent diagnosis of CAD. December 2009, Private treatment record; VA treatment records dated December 2011 and February 2013. The Board, accordingly, finds competent evidence of a current disorder. The evidence demonstrates that the Veteran had first-degree atrioventricular (AV) block prior to active service as noted on November 1996 and September 2001 ECGs. Medical treatment records dated November 1996 and September 2001. Accordingly, the presumption of soundness does not apply. See 38 C.F.R. §§ 3.303, 3.304. In 2012, Dr. G.G. and the Veteran’s primary care physicians, Drs. S.I., C.P., and H.C., opined the Veteran’s first-degree AV block was aggravated by military service resulting in triple bypass surgery and CAD. The private physicians reviewed the 1996, 2001, 2002, 2008, and 2009 ECGs, diagnoses of bradycardia sinus rhythm and first-degree AV block, and noted the Veteran is a nonsmoker with no prior or family history of CAD. Dr. S.I. explained bradycardia is caused by disruption in normal electrical impulses controlling the rate of heart contractions and can be progressive; additionally, the progression of CAD can be affected by an individual’s stress level. Drs. S.I. and G.G. reasoned the Veteran’s stress related to military service accelerated the progression of CAD and found the in-service ECG pointed to early stages of CAD. July 2012, Correspondence by Dr. S.I.; July 2012, Correspondence by Dr. G.G.; September 2012, Correspondence by Dr. C.P.; May 2016, Medical Nexus Statement by S.I.; May 2016, Correspondence. In April 2013, a VA examiner opined first degree AV block and bradycardia were not aggravated beyond its natural progression in military service. The examiner acknowledged the Veteran had first degree AV block in November 1996, prior to service, was asymptomatic, and in excellent health. The examiner reasoned medical literature provides no plausible explanation that military service aggravates an intrinsic disease of the electrical system of the heart. He further stated the ECGs of record do not indicate early stage CAD or ischemia, and ECGs are not reliable tests for CAD. The examiner also acknowledged the opinions of Drs. G.G., S.I., and C.P., but found there were no STRs showing stress related systems and believed some of their statements regarding the Veteran’s military history were inaccurate. April 2013, VA examination. At the Board hearing, the Veteran testified he began feeling tired and sluggish after deployment to Afghanistan. He further stated he experienced a great deal of stress in performing his MOS—ensuring teams around the world received up-to-date logistics and support during the war on terror; the well-being of his family and maintaining his civilian employment also contributed to his stress level. February 2020, Hearing transcript. In light of the foregoing, the Board finds military service aggravated the Veteran’s preexisting heart condition and there is no clear and unmistakable evidence of record to rebut the presumption of aggravation. The Board acknowledges the April 2013 VA examiner’s opinion that first-degree AV block was not aggravated by military service but assigns little probative weight as the examiner did not have the opportunity to consider the Veteran’s lay statements concerning military stress and onset of symptoms. See October 2016, Correspondence; February 2020, Hearing transcript; see also Dalton v. Nicholson, 21 Vet. App. 23 (2007) (a medical opinion is inadequate if it does not take into account the Veteran’s reports of symptoms and history); Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993) (medical opinions based on an incomplete or inaccurate factual premise are not probative). Conversely, the Board accords high probative weight to Drs. S.I. and G.G.’s opinions that military stress aggravated first-degree AV block beyond its natural progression because Dr. S.I. treated the Veteran since 2008, considered relevant medical records and the Veteran’s lay statements concerning military stress, reviewed all ECGs of record, and provided clear clinical findings supported by data. See July 2012, Correspondence by Dr. S.I.; July 2012, Correspondence by Dr. G.G.; May 2016, Medical Nexus Statement by S.I.; Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board also finds the Veteran’s lay statements concerning the onset of his symptoms and stress level during military service to be competent and credible evidence of in-service aggravation and accords high weight to same. See October 2016, Correspondence; February 2020, Hearing transcript; see also Jandreau, 492 F.3d at 1377. The Board further finds that there is not clear and unmistakable evidence that the increase in disability was due to the natural progression of the condition. Resolving all reasonable doubt in favor of the Veteran, service connection for CAD based on in-service aggravation is warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. JAMES L. MARCH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Straughn, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.