Citation Nr: 20034401 Decision Date: 05/18/20 Archive Date: 05/18/20 DOCKET NO. 16-55 593 DATE: May 18, 2020 ORDER 1. Entitlement to service connection for a cardiovascular disorder (other than hypertension) also claimed as cardiac impairment, to include atrial fibrillation, is denied. 2. Entitlement to an initial compensable disability rating for hypertension is denied. FINDINGS OF FACT 1. The Veteran’s current cardiovascular disorder of atrial fibrillation did not manifest in service or within one year of separation from active duty, and it is not otherwise caused by or related to the Veteran’s active duty. 2. The Veteran’s hypertension has not manifested with diastolic pressure predominantly 100 or more, or systolic pressure predominantly 160 or more, and the Veteran is not an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control of her symptoms. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a cardiovascular disorder (other than hypertension) also claimed as cardiac impairment, to include atrial fibrillation, have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 1137, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309. 2. The criteria for entitlement to an initial compensable disability rating for hypertension have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.104, Diagnostic Code (DC) 7101. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty from November 1982 to June 1987 and from May 2000 to July 2010. She also had service in the Air Force National Guard from June 1991 to May 2000. The Veteran’s service connection claim for a cardiovascular disorder was previously before the Board in October 2017 and October 2018, at which times, the Board remanded it to the Agency of Original Jurisdiction (AOJ) to associate outstanding VA treatment records, to ask the Veteran to identify any outstanding private treatment records, and to provide the Veteran with a VA examination. A review of the record reflects substantial compliance with the Board’s October 2017 and October 2018 remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). 1. Service Connection for a Cardiovascular Disorder The Veteran contends that her current cardiovascular disorder of atrial fibrillation manifested in service or was caused by her active duty. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). “To establish a right to compensation for a present disability, 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.” Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010). Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Service connection may also be established under 38 C.F.R. § 3.303(b), if a chronic disease or injury is shown in service, and subsequent manifestations of the same chronic disease or injury at any later date, however remote, are shown, unless clearly attributable to intercurrent causes. Service connection may also be established under 38 C.F.R. § 3.303(b), where a condition in service is noted but is not, in fact, chronic, or where a diagnosis of chronicity may be legitimately questioned. The continuity of symptomatology provision of 38 C.F.R. § 3.303(b) has been interpreted as an alternative to service connection only for the specific chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 718 F.3d 1331, 1340 (Fed. Cir. 2013). Cardiovascular-renal disease is a chronic disorder listed under 38 C.F.R. § 3.309; thus, 38 C.F.R. § 3.303(b) is applicable for Veteran’s claim. Additionally, where a veteran served 90 days or more of active service, and certain chronic diseases, such as cardiovascular-renal disease, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. However, where the evidence does not warrant presumptive service connection, a veteran is not precluded from establishing service connection with proof of direct causation. See Combee, 34 F.3d at 1043. When all the evidence is assembled, the Board is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the Veteran. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. In deciding claims, it is the Board’s responsibility to evaluate the entire record on appeal. See 38 U.S.C. § 7104(a). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss each and every piece of evidence submitted by the Veteran or on her behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Rather, the Board’s analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). The Veteran contends that her cardiovascular disorder began during her active duty. Regarding the first element of service connection, the record shows that the Veteran has been diagnosed with a current cardiovascular disorder, other than hypertension, during the appeal. For example, a June 2019 VA examination report shows that she was diagnosed with atrial fibrillation. Thus, she has a current disability and the first element of service connection is met. Regarding the second element of service connection, namely, an in-service incurrence or aggravation of a disease or injury, the Veteran’s service treatment records show that the Veteran complained in an April 1985 treatment record of a history of a heart murmur as a child that healed as she got older. The medical professional documented that the Veteran reported that she had a murmur until about 12 years old and that she was told not to participate in sports until the murmur resolved. The medical professional noted that the Veteran was unrestricted in her activities at that time. Moreover, an April 2009 endocrine consultation note showed that the Veteran complained of palpitations, although she had regular sinus rhythm and no murmur, rub, gallop, or click noted. She also denied chest pain or tightness, dyspnea on exertion, peripheral edema, and leg pain with exertion. Thus, the second element of service connection is met, and the only question to be answered is whether the Veteran’s current atrial fibrillation manifested in service or within one year of separation from service, or is otherwise related to her active duty. The Board notes that apart from these two notations related to abnormal symptoms, the Veteran’s service treatment records do not show any other complaints of abnormal cardiovascular symptoms. In fact, the Veteran denied having a history of heart trouble and her heart and/or cardiovascular system was noted to be normal in numerous service treatment records and evaluations, in including in April 1982, July 1985, May 1991, April 1996, November 1997, October 1998, May 2000, October 2004, April 2005, November 2008, October 2009, December 2009, January 2010, April 2010, and July 2010. The Veteran was afforded a VA examination in July 2010, during which the examiner determined that she had hypertensive vascular disease, but her heart showed normal sinus rhythm and no clinical cardiomegaly or murmurs. The Board notes that the Veteran’s hypertensive vascular disease or hypertension is already a service-connected disability. In April 2014, the Veteran filed the present claim for service connection, in which she contended that her cardiac impairment, to include atrial fibrillation, was secondary to her time in service. The Veteran was afforded another VA examination in April 2019, during which the examiner diagnosed her with atrial fibrillation. The Veteran reported that she started having arrythmias in 2005 while in Japan. Specifically, she stated that she started having issues with heart rapidly beating while on active duty in Japan 2005, and that she separated from military duty as an air traffic controller in 2010. She told the examiner that she had an episode with active atrial fibrillation lasting over eight hours in 2014. The Veteran also reported that she had an acute episode in 2018 requiring hospitalization with planned cardioversion, which resolved on its own with medication. The examiner noted that she was currently on anticoagulant medication and that she functioned as an Air Traffic Controller from 1982 to 2010 while on active duty. The examiner opined that the Veteran’s current atrial fibrillation disability was less likely as not (less than 50 percent probability) incurred in or caused by the claimed-in-service injury, event, or illness. The examiner explained that although the Veteran reported the first episode of atrial fibrillation during active duty, a thorough search of the claims file failed to show any documentation of this episode or of the Veteran being seen by a medical provider for this disorder. The examiner noted that the Veteran began having more episodes of atrial fibrillation, with the most recent being in 2014, or four years after her discharge from active duty. The examiner noted that prior to 2014, the Veteran was not seen or treated for atrial fibrillation while on active duty. The Veteran underwent another VA examination for the cardiovascular disorder in June 2019, during which the examiner again diagnosed her with atrial fibrillation. The Veteran reported that during her active duty working as an air traffic controller, she had episodes of heart fluttering, palpitations, and skipping beats lasting up to one hour on a daily basis. She stated that the episodes became more frequent as time went by between 2008 and 2010. She also reported that in March 2014 she had a prolonged episode and was transported to the local emergency room and was started on coumadin medication, and that she was switched to Pradaxa medication in 2018. The examiner noted that the atrial fibrillation was idiopathic. Following the examination, the examiner opined that the current atrial fibrillation was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that there was no nexus between the palpitations in service. The examiner further noted that the Veteran’s service treatment records, as well as post-service records, show that she complained of palpitations in April 2009 during an endocrinology consultation. However, there was no evidence of followup or further complaints of palpitations after separation from service until four years later. The examiner noted that the Veteran was diagnosed with paroxysmal atrial fibrillation in 2014 and started on lifelong anticoagulation therapy. Given this evidence, the Board finds that the preponderance of the evidence is against a finding that the Veteran’s current atrial fibrillation manifested in service or within one year of separation from active duty service, and it is not otherwise caused by or related to the Veteran’s active duty. The Board acknowledges the Veteran’s contentions that this disability had its onset in service and notes that she is competent to report symptoms that she perceived through her own senses. However, she is not competent to offer opinions as to the cause of her current atrial fibrillation due to the medical complexity of the matter involved. This disorder requires specialized training for a determination as to diagnosis, causation, and progression, and is therefore not susceptible to lay opinions on causation or aggravation. Thus, the Veteran is not competent to render an opinion or attempt to present lay assertions to establish the causation of her current atrial fibrillation disability. The April 2019 and June 2019 VA examiners’s opinions, which are competent on the issue of causation of medically complicated matters, are of more probative value. These examiners concluded that the Veteran’s atrial fibrillation was less likely than not caused by or otherwise related to her active duty service, and they noted that this disability manifested approximately four years following her separation from active duty in July 2010. These examiners’s opinions are highly probative evidence regarding the cause of the Veteran’s current disability because of the examiners’s expertise, training, education, proper support and explanations, and thorough review of the Veteran’s records and self-reported symptoms. Therefore, as the preponderance of the evidence is against entitlement to service connection for a cardiovascular disorder (other than hypertension), also claimed as cardiac impairment, to include atrial fibrillation, the benefit of the doubt doctrine does not apply, and the Veteran’s claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). 2. Increased Rating for Hypertension The Veteran contends that her service-connected hypertension should be rated higher than the currently-assigned noncompensable disability rating. VA has adopted a Schedule for Rating Disabilities (Schedule) to evaluate service-connected disabilities. See 38 U.S.C. § 1155; 38 C.F.R., Part IV. Disability evaluations assess the ability of the body as a whole, the psyche, or a body system or organ to function under the ordinary conditions of daily life, to include employment. 38 C.F.R. § 4.10. The percentage ratings in the Schedule represent the average impairment in earning capacity resulting from service-connected diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The percentage ratings are generally adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the disability. Id. In disability rating cases, VA assesses the level of disability from the initial grant of service connection or a year prior to the date of application for an increased rating and determines whether the level of disability warrants the assignment of different disability ratings at different times over the course of the claim, a practice known as “staged ratings.” The record shows that the Veteran appealed the initially-assigned disability rating; thus, the appeal period stems from July 24, 2010, which is the first day following the Veteran’s separation from active duty. The Veteran’s hypertension is evaluated under DC 7101, which provides ratings for hypertensive vascular disease (hypertension and isolated systolic hypertension). Hypertensive vascular disease with diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 160 or more, or; minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control, is rated 10 percent disabling. Hypertensive vascular disease with diastolic pressure predominantly 110 or more; or, systolic pressure predominantly 200 or more, is rated 20 percent disabling. Hypertensive vascular disease with diastolic pressure predominantly 120 or more is rated 40 percent disabling. Hypertensive vascular disease with diastolic pressure predominantly 130 or more is rated 60 percent disabling. 38 C.F.R. § 4.104, DC 7101. Note (1) provides that hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. For purposes of this section, the term hypertension means that the diastolic blood pressure is predominantly 90 mm or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160 mm. or greater with a diastolic blood pressure of less than 90 mm. Id. at Note (1). An April 2010 service treatment record, which occurred prior to the current appeal, showed that the Veteran’s systolic blood pressure was 124 and the diastolic blood pressure was 74, or 124/74. Overall, the evidence shows that she has been taking medication to treat her hypertension symptoms throughout the appeal. Blood pressure readings during a July 2010 VA examination were 140/95, 137/94, and 141/94. The Veteran was diagnosed with hypertensive vascular disease. Furthermore, a March 2011 VA examination showed blood pressure readings of 156/83, 163/89, and 162/89. Moreover, an April 2019 VA examination showed that the Veteran’s blood pressure was 146/84, 149/86, and 173/83. VA treatment records from March 2011 show that the Veteran’s blood pressure was 155/80 and 150/70. Likewise, VA treatment records from January 2012 show blood pressure of 137/83 and of 125/72 in December 2012. A November 2013 VA treatment record showed blood pressure of 125/72 and a March 2014 VA treatment record showed blood pressure of 123/77. Similarly, the Veteran’s blood pressure was noted to be 111/70 in January 2015, 160/76 in April 2015, 106/67 in July 2015, 121/75 in June 2016, 132/79 in October 2016, 107/66 in April 2017, 129/75 in May 2018, 129/89 in August 2018, 116/71 in May 2019, and 120/87 in June 2019. Given this evidence, the Board finds that the Veteran’s hypertension has not manifested with diastolic pressure predominantly 100 or more, or systolic pressure predominantly 160 or more, and that the Veteran is not an individual with a history of diastolic pressure predominantly 100 or more prior to going on medication. While the record shows that the Veteran has been required to take medication to treat her symptoms, and the record shows that the systolic blood pressure has been in excess of 160 on several occasions during the appeal, the preponderance of the evidence is against a finding that her systolic blood pressure has been predominantly 160 or more and her diastolic blood pressure has been predominantly 100 or more at any time during the appeal. Accordingly, the evidence does not show that the Veteran’s disability picture warrants an initial compensable disability rating for hypertension during the appeal. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule does not apply, and the Veteran’s claim for an increased rating is denied. See 38 C.F.R. §§ 4.3, 4.104, DC 7101; Gilbert, 1 Vet. App. at 55. A. P. SIMPSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Hodzic, 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.