Citation Nr: 20060625 Decision Date: 09/15/20 Archive Date: 09/15/20 DOCKET NO. 16-19 186 DATE: September 15, 2020 ORDER Entitlement to service connection for a cardiovascular disability, to include disability manifested by syncope, disability manifested by atrial septal defect, orthostatic hypertension, mitral valve prolapse and mitral regurgitation, is denied. FINDING OF FACT The most probative evidence of record is against a finding that the Veteran has a current cardiovascular disability, including disability manifested by syncope, disability manifested by atrial septal defect, orthostatic hypertension, mitral valve prolapse and mitral regurgitation that is etiologically related to her military service. CONCLUSION OF LAW The criteria for service connection for a cardiovascular disability, to include disability manifested by syncope, disability manifested by atrial septal defect, orthostatic hypertension, mitral valve prolapse and mitral regurgitation, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from November 1993 to July 1994. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a Board hearing at the Winston Salem, North Carolina RO before the undersigned in March 2019. A transcript of the hearing is of record. In July 2019, the case was remanded for further development. The Veteran alleges that she has a current cardiovascular disability related to service, to include disability manifested by syncope, disability manifested by atrial septal defect, orthostatic hypertension, mitral valve prolapse and mitral regurgitation. Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Service connection may be granted for any disease diagnosed after discharge, when the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing entitlement to direct service connection generally requires: (1) competent and credible evidence confirming the Veteran has the claimed disability or, at the very least, showing he has at some point since the filing of his claim; (2) competent and credible evidence of in-service incurrence or aggravation of a relevant disease or an injury; and (3) competent and credible evidence of a relationship or correlation between the disease or injury in service and the currently claimed disability - which is the so-called “nexus” requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant; however, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 C.F.R. § 3.102. The Veteran’s service treatment records show that she was seen by medical personnel in January 1994 and February 1994 for complaints of light-headedness and dizziness. At a February 1994 visit, the Veteran reported frequent sensations of dizziness and of having at least 4 episodes of syncope. It was noted that she had recently gone to the emergency room where she was treated for bronchitis and volume depletion. The diagnostic assessment was again volume depletion. The Veteran was admitted to a minimal care hospital ward for IV hydration. The Veteran was hospitalized for 14 days and the pertinent discharge diagnosis was orthostatic hypertension. It was noted that she experienced frequent dizziness on the hospital ward. An April 1994 physical profile report indicates that the Veteran was given a profile for postural hypotension/syncope. She was found not to be world-wide deployable, not capable of field training and unable to perform duties of any MOS secondary to her medical condition, and she was referred for Medical/Physical Evaluation Board Proceedings. The profile entailed that she walked at her own pace and distance. An April 1994 report of Medical Evaluation Board Proceedings indicates that the Veteran had postural hypotension and syncope secondary to either a variant of orthostatic tachycardiac syndrome and/or vasovagal syncope. She was found to have an intra-atrial septal aneurysm of no clinical significance. The approximate date of origin for this condition was deemed to be January 30, 1994. It was noted that the Veteran did not desire to continue active duty. A May 1994 Physical Evaluation Board (PEB) Proceedings decision indicates that the Veteran’s postural hypertension and syncope secondary to either a variant of orthostatic tachycardic hypotension syndrome and/or vasovagal syncope was not unfitting and not unratable. The PEB concluded that based on the evidence of record, the proper disposition for the Veteran was separation with severance pay. The PEB found that the Veteran was physically unfit and recommended a combined disability rating of 10 percent. A June 2008 record from North Carolina Emergency Medical Services, Region I shows that the Veteran suffered a motor vehicle crash. At the scene of the accident she reported that she was driving back from her mother’s house when she realized that she was light-headed and dizzy. She stated that she did not black out but her car hit a power pole rear end first. The Veteran was up and walking around before the ambulance came on the scene. She was taken by ambulance to Forsyth Medical Center. During this time, she was placed on an ECG monitor and placed on oxygen. She was also given an IV in left arm and she passed a stroke screening without any problems. She was subsequently seen at the emergency room where she was found to have a single rib fracture and noted to have had an episode of syncope. Her fainting was found to be of uncertain cause, and she was advised to follow up with a private family practice clinic in about one week for recheck. A May 2012 private emergency room record shows that the Veteran was seen for complaints of dizziness. It was noted that she was moving some boxes at work when she developed dizziness. She felt a bit of nausea, broke out in sweats and felt a bit hot. The next thing she remembered was that after she recovered, her co-workers informed her that she had passed out. She denied chest pain, palpitations, shortness of breath or pre-existing syncopal episode. She indicated that she had had a similar syncopal episode at home within the past year. She reported that she was discharged from the military ten years previously due to valvular heart disease. She also reported that in the past year she had been admitted to the hospital for valvular heart disease. The diagnostic assessment was history of syncopal episode and the Veteran was admitted to a telemetry unit for evaluation. An echocardiogram showed preserved left ventricular function with mitral valve prolapse, mitral regurgitation and small patent foramen ovale. A May 2012 discharge summary shows that the Veteran stayed in the hospital just a short time and was noted to have improved a lot, as she was no longer experiencing dizziness. She was discharged home and advised to follow-up with her primary care doctor and with cardiology. In September 2013, the Veteran filed her initial claim for service connection for cardiovascular disability, including orthostatic hypertension, syncope and atrial septal aneurysm. At a June 2014 VA examination, the Veteran reported that after discharge she was followed for a while by a physician. However, these records were not available. She stated that she had not been able to afford medical care for herself over the past 10 to 14 years. The examiner noted the treatment in 2012 for the near syncopal event at work and that acute coronary syndrome was ruled out at that time. On examination, the Veteran was diagnosed with valvular heart disease, mild mitral regurgitation and mild mitral valve prolapse, and atrial septal defect. EKG testing showed non-specific ST-T wave changes and sinus brachycardia with a ventricular rate of 55. METS evaluation showed that the Veteran denied experiencing symptoms with any level of physical activity. The examiner found that the Veteran’s heart condition did not impact her ability to work. After examination and review of the claims file, the examiner opined that the Veteran’s current condition was less likely than not incurred in or caused by any claimed in-service injury, event or illness. The examiner indicated that the medical evidence did not support a current diagnosis of orthostatic hypotension or a diagnosis of recurrent or chronic syncope due to any medical condition. The post-service medical evidence only demonstrated one episode of syncope occurring while at work in 2012 without evidence of orthostasis. The mitral valve prolapse noted on echocardiogram in 2012 was not present in 1994 per echocardiogram performed at that time. The service treatment records demonstrated that the Veteran was discharged from the military in 1994 due to the symptoms related to orthostatic hypotension. However, there was no evidence of continuity of care and no current evidence per exam findings of orthostatic hypotension. The small atrial septal defect was considered benign and would not be expected to cause syncope. The atrial septal defect was a congenital condition without evidence of permanent aggravation due to military service. At an August 2014 VA emergency department visit, the Veteran was complaining of chest pain. It was noted that she was briskly walking 2+ miles per day and had been experiencing on and off chest wall pain. It was also noted that she worked in a factory and did a lot of lifting. Additionally, it was noted that the Veteran had a history of mitral valve prolapse in the past but no tachycardiac events in the past nor currently. EKG and oxygen saturation tests were normal. It was also noted that symptom relief was obtained with a cocktail of gastrointestinal medication and Toradol. The Veteran was discharged home with the instruction to start the gastrointestinal medication omeprazole daily, along with Mylanta as needed. An August 2014 VA chest X-ray also showed mild COPD changes. A subsequent September 2014 VA emergency room note indicates that the Veteran was again seen for intermittent, recurrent non-exertional chest pain that had been non-revealing with negative cardiac work-up, including normal echocardiograms, negative cardiac enzyme testing and normal D dimer testing (used to help rule out the presence of an inappropriate blood clot). The Veteran reported that the pain was so severe at times that she could not perform her job duties and was accompanied by dyspnea. There was no radiation, diaphoresis, light-headedness or palpitation. In her September 2014 notice of disagreement, the Veteran contended that the service treatment records showed a constant complaint concerning her medical condition, along with treatment for it. She asserted that it was obvious that even a lay person could determine a connection between the two conditions. She noted that the fact that private medical records had not yet been retrieved (concerning potential additional treatment for the condition) did not preclude her claimed condition from being service connected. February 2016 VA stress test echocardiogram testing showed normal systolic function with an ejection fraction of 55 to 60 percent. There were no regional wall abnormalities noted. There was normal augmentation of all left ventricular wall segments post-exercise. There was a maximum 1 ST segment depression and diffuse T-wave inversion in recovery, which could be non-specific. The Veteran achieved 13.4 METS, which was found to be excellent. There was no evidence for mitral valve prolapse. The Veteran’s primary care physician informed her that her heart was pumping relatively well and that no mitral valve prolapse was seen. At the March 2019 Board hearing, the Veteran testified that she experienced episodes of dizziness and fainting during service. She also indicated that she continued to experience such episodes. She noted that she would start to get very light-headed and then black out for a few seconds. She reported that she would get disoriented and the problem would throw her whole day off. She indicated that she experienced memory loss and pounding in her chest. She testified that when she had one of these episodes that was more acute, she usually ended up in the hospital where she was administered IV fluids. The Veteran testified that her most recent treatment had been approximately six months previously and that at the hospital, staff had administered orthostatic tests, lying down, sitting and standing. She noted that staff also administered IV fluids and then ensured she was feeling strong enough that she could be released back home. She also reported that she saw a cardiologist at the VA facility about once per year and was due to go back for an evaluation very soon. She indicated that she could have these spells of dizziness and blacking out about once a week and sometimes two or three times per week and that she had not discerned a specific pattern to them. She stated that no effective treatment for the spells had been found. The Veteran also testified that she was told in the military that she had mitral valve prolapse, which involved the valve being closed when it is supposed to be open and would be open when it was supposed to be closed. At an April 2019 VA primary care visit, the Veteran reported that she had work-up in service for syncope, including tilt table testing and other studies. She indicated that she was trying to establish service connection for cardiovascular disability but was told that her condition was ‘congenital.’ The physician noted that the echocardiogram in 2016 did not show mitral valve prolapse or any other issue. The physician commented that she was not able to complete a positive medical nexus opinion based on the information she had. She indicated that the Veteran’s history was not clear, and her heart seemed normal. The above summarized evidence does not show that the Veteran has any current cardiovascular disability, including disability manifested by syncope, orthostatic hypertension, disability due to atrial septal defect/aneurysm, or disability due to valvular heart disease, to include mitral valve prolapse and/or mitral regurgitation that is etiologically related to her military service. In this regard, the June 2014 VA examiner commented that the post-service medical evidence only demonstrated one episode of syncope occurring while at work in 2012 without evidence of orthostasis. The examiner also commented that there was no evidence of continuity of care since service and no current examination findings of orthostatic hypertension. Additionally, the small atrial defect noted in service was a congenital condition that was not shown to be aggravated by service (nor was it found to result in any disability/functional impairment). Also, during the August and September 2014 VA emergency visits, the Veteran was noted to have a history of mitral valve prolapse but was not found to have any current cardiovascular disability. Additionally, the February 2016 VA stress test echocardiogram showed that the Veteran had an excellent METS level of 13.4, no mitral valve prolapse and a heart that was pumping relatively well. These findings are also not indicative of any current cardiovascular disability/functional impairment due to cardiovascular symptomatology. Moreover, at the April 2019 VA primary care visit, the evaluating physician commented that she was not able to provide a positive medical nexus opinion for the Veteran because the echocardiogram in 2016 did not show mitral valve prolapse or any other issue and the Veteran’s heart seemed normal. This finding is also not indicative of the presence of any current cardiovascular disability/functional impairment. Further, there is no medical evidence to the contrary (i.e. evidence tending to indicate that the Veteran does have a current cardiovascular disability, to include disability manifested by syncope, orthostatic hypertension, atrial septal defect, or disability due to valvular heart disease, to include mitral valve prolapse and/or mitral regurgitation). Notably, the May 2012 VA private emergency room record did show an episode of syncope that appeared to be associated with mitral valve prolapse and regurgitation. However, this finding was made prior to the period for which the Board may consider whether a current disability is present (i.e. the period from when the Veteran filed her claim for service connection in September 2013). At the March 2019 Board hearing, the Veteran testified that she has continued to experience episodes of dizziness and fainting from service up until the present. However, the Board presumes that had these symptoms continued in this manner with such frequency, the Veteran would have reported this symptomatology to her treating medical providers at some point after May 2012, just as she reported several other medical problems to them. See VA treatment records dated from June 2014 to July 2020. However, as alluded to above, there is no medical evidence of any such symptomatology after May 2012. Accordingly, the Board is not able to find credible the Veteran’s report of continued problems with dizziness and fainting/syncope after May 2012 and must credit the information contained in the medical treatment records, which does not show any such symptomatology. At the Board hearing, the Veteran also testified that she had received evaluation and treatment for apparent orthostatic hypertension at Wilkes Regional Medical Center in approximately 2018. To date, the Veteran has not submitted any records from this provider in conjunction with her claim. Also, pursuant to the July 2019 remand, the agency of original jurisdiction provided releases of information in both November 2019 and January 2020 so that she could authorize VA to obtain any outstanding private treatment records, including any records from Wilkes Regional Medical Center. However, the Veteran did not return a release of information for this facility and VA was not able to attempt to obtain these records. Accordingly, the Board is not able to consider them in determining whether a current cardiovascular disability is present in this case. To the extent that the Veteran has a current cardiovascular disability, the most probative evidence of record does not reflect that it is etiologically related to her military service. The preponderance of the evidence is against this claim and it must be denied. 38 C.F.R. § 3.303; Alemany, 9 Vet. App. 518 (1996). S. HENEKS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Dan Brook, 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.