Citation Nr: 21003063 Decision Date: 01/19/21 Archive Date: 01/19/21 DOCKET NO. 14-22 536 DATE: January 19, 2021 ORDER Entitlement to service connection for a heart disability (previously claimed as paroxysmal atrial fibrillation and heart condition), to include as due to herbicide exposure, and to include as secondary to a service-connected disability is denied. FINDING OF FACT The objective medical evidence shows that the Veteran’s heart disability was not caused by an event, injury, or illness during active service, nor is it proximately due to, the result of, or permanently made worse beyond its natural progression by service-connected diabetes. CONCLUSION OF LAW The criteria for establishing service connection for a heart disability, to include as due to herbicide exposure, and to include as secondary to a service-connected disability have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1116, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active duty service in the United States Army from March 1966 to March 1968. The Veteran’s claim of entitlement to service connection for paroxysmal atrial fibrillation was originally denied in a March 2013 rating decision. The claim was remanded by the Board in February 2016 and February 2020 for additional development. The claim is now properly before the Board for appellate review. Entitlement to service connection for a heart disability (previously claimed as paroxysmal atrial fibrillation and heart condition), to include as due to herbicide exposure, and to include as secondary to a service-connected disability Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§1110, 5107; 38 C.F.R. §3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(b); Allen v. Brown, 7 Vet. App. 439 (1995). Service connection for some chronic diseases, including cardiovascular disease, may be presumed to have been incurred in service if manifested to a compensable degree within 1 year following separation from qualifying service. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. VA shall consider all information and lay and medical evidence of record in a case and make appropriate determinations as to competence, credibility, and weight. 38 U.S.C. § 5107; Washington v. Nicholson, 19 Vet. App. 362, 368 (2005); 38 C.F.R. § 3.303. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159. Competent lay evidence also means any evidence not requiring that the proponent have specialized education, training, or experience. 38 C.F.R. § 3.159. 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 claimant. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. When the preponderance of the evidence weighs against the claims of the Veteran, the claim will be denied on its merits, and when the preponderance of the evidence weighs for the claims of the Veteran, the claim will be granted on its merits; in such cases, the benefit of the doubt doctrine is inapplicable. 38 U.S.C. § 5107. The Veteran contends that his heart disability is related to his active duty service or secondary to his service-connected disabilities including diabetes mellitus. He asserts that he was exposed to Agent Orange during field exercises on the “Big Island” of Hawaii. Veterans who served in specific locations, such as the Republic of Vietnam during the Vietnam era, are presumed to have been exposed to certain herbicide agents (e.g., Agent Orange), however veterans who served in other locations may also have been exposed to herbicide agents.38 U.S.C. §1116; 38 C.F.R. § 3.307. As such, service connection may be presumed for certain diseases if a veteran was exposed to an herbicide agent during service, and the disease manifested to a degree of ten percent or more any time after service. 38 C.F.R. §§ 3.307(a)(6), 3.309(e). Ischemic heart disease, as defined in the regulation is one such disease. Id. In its February 2020 decision, the Board concluded, on a facts-found basis, that the Veteran’s active service while in Hawaii at his specific training locations exposed him to an area or areas recently treated with herbicides, including Agent Orange. However, this service location is not one for which in-service herbicide exposure is presumptively conceded, and the Veteran’s heart disability is not a condition that VA recognizes as etiologically related to herbicide exposure. See 38 C.F.R. §§ 3.307(a)(6), 3.309(e). It is not defied as ischemic heart disease pursuant to regulation. Id. Nevertheless, when service connection cannot be granted on a presumptive basis, a veteran may still establish service connection on a direct basis. See Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). In this case, regarding the first element of service connection, the Veteran has a current diagnosis of paroxysmal atrial fibrillation and valvular heart disease. 38 C.F.R. § 3.385. See VA examinations dated February 2013 and July 2020. Therefore, the first element of service connection has been met. The Board notes that during his February 1968 separation examination, abnormal heart findings were noted to include a grade 2/6 functional systolic heart murmur. His service treatment records (STRs) are otherwise silent as to any complaints or treatment for heart problems. Private treatment records indicate complaints and treatment for symptoms including dizziness and heart palpitations beginning in 2011, and surgery to insert a pacemaker in 2012. The Veteran was afforded a VA examination for heart conditions in February 2013. The examiner confirmed the Veteran’s diagnosis of paroxysmal atrial fibrillation and opined that the Veteran’s heart disability was less likely than not incurred during or etiologically related to his active duty service. He also diagnosed the Veteran with heart valve conditions involving the mitral, tricuspid, and aortic valves. He acknowledged the Veteran’s heart murmur noted upon discharge from service and the onset of his symptoms and pacemaker. The examiner explained that a functional murmur like the one noted during the Veteran’s separation examination is primarily due to physiologic conditions outside the heart, as opposed to structural defects in the heart itself. He stated that the Veteran's murmur is more consistent with an adult variant of a “Still's murmur” and that it is not pathologic, meaning no disease state results from its presence. Therefore, he concluded that the heart murmur that he had at separation was a functional systolic murmur and not known to be associated with later development of the Veteran’s current arrythmia. He stated that a review of the Veteran's record indicates that Veteran has many risk factors for paroxysmal atrial fibrillation including hypertensive heart disease and poorly controlled diabetes. In the February 2020 Board decision, service connection was granted for diabetes mellitus, type II, and the issue of service connection for paroxysmal atrial fibrillation was remanded for further development. Pursuant to the February 2020 remand, the Veteran was afforded a VA examination for heart conditions in July 2020. The examiner opined that the Veteran’s heart disability was less likely than not incurred in or otherwise etiologically related to his active duty service, to include Agent Orange exposure. He also opined that his current heart disability is less likely than not due to or aggravated by his service-connected diabetes. He noted that heart murmurs such as the one present at the Veteran’s separation examination are made by blood circulating through the heart's chambers and can be present at birth or develop later in life. He stated that often heart murmurs are harmless (innocent) and don't need treatment, and the Veteran’s heart murmur is considered an innocent murmur, which may disappear and then reappear. He therefore concluded that there is no medical evidence to suggest that the murmur was caused by a heart valve disease while in the service or is related to his current heart disability. He stated that atrial fibrillation is a common heart rhythm condition due to damage to the heart's electrical system. He further stated that hypertension is the most common risk factor for atrial fibrillation, and the Veteran has hypertension which appeared to pre-date his diabetic condition. He noted that the current medical literature does not support an association between herbicide exposure and atrial fibrillation and the Veteran was not diagnosed until 43 years after separation from service. Therefore, he determined that it is less likely than not that the Veteran’s current heart disability is etiologically related to service or a service-connected disability to include diabetes mellitus. The Board determines that the preponderance of the evidence shows that the Veteran's current heart disability was not incurred in or related to service nor was it caused or aggravated by his service-connected diabetes mellitus. The Board finds the reasoning of the July 2020 VA examiner to be highly probative as the examiner indicated a detailed review of the evidence, provided a fully supported rationale consistent with the evidence, and considered the Veteran's medical history. Importantly, the examiner noted that the Veteran's heart disability pre-dated his earliest diagnosis of diabetes mellitus and thus, was not caused by or aggravated by his diabetes mellitus. The Board notes that Veteran is competent to report his observable symptoms; however, making a determination regarding the etiology of a disability requires medical expertise and knowledge which is beyond the scope of a lay person’s knowledge. Thus, the Veteran’s assertions are not competent evidence of a nexus between his current heart disability and service or a service-connected disability. 38 C.F.R. § 3.159(a)(1), (2). In sum, the most probative evidence of record demonstrates that the Veteran's heart disability was not incurred in or aggravated by service nor was it caused or aggravated by his service-connected diabetes mellitus. Therefore, the Veteran's claim for service connection for a heart disability is denied. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. 38 U.S.C. § 5107. MICHAEL D. LYON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board L. Sneeringer, 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.