Citation Nr: 21064246 Decision Date: 10/19/21 Archive Date: 10/19/21 DOCKET NO. 16-53 692A DATE: October 19, 2021 ORDER Entitlement to service connection for a myocardial infarction is denied. FINDING OF FACT The Veteran's myocardial infarction was not manifest or otherwise attributable to his June 2000 period of active duty for training (ACDUTRA). CONCLUSION OF LAW The criteria to establish service connection for a myocardial infarction are not met. 38 U.S.C. §§ 1110, 1112, 1113, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from January 1970 to June 1970, October 1970 to September 1976, February 1991 to May1991, and subsequent ACDUTRA that included a period of ACDUTRA from June 1, 2000, to June 14, 2000. The Veteran died in January 2018, and the Appellant is the Veteran's surviving spouse. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2015 rating decision by the Department of Veterans Affairs (VA). In June 2019, the Board remanded the claim for further development. Here, substantial compliance with the Board's prior remand orders is demonstrated. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); Stegall v. West, 11 Vet. App. 268, 271 (1998). 1. Entitlement to service connection for a myocardial infarction. Service Connection Laws A Veteran is a person who served in the active military, naval, or air service and who was discharged or released under conditions other "than dishonorable." 38 C.F.R. § 3.1(d). The term "active military, naval, or air service" includes: (1) active duty; (2) any period of ACDUTRA during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in the line of duty; and (3) any period of INACDUTRA during which the individual concerned was disabled or died from an injury incurred or aggravated in the line of duty or from an acute MI, a cardiac arrest, or a cerebrovascular accident which occurred during such training. 38 U.S.C. § 101(24); 38 C.F.R. § 3.6(a). ACDUTRA includes full-time duty performed by members of the National Guard of any State or the Reserve. 38 C.F.R. § 3.6(c). INACDUTRA includes duty other than full-time duty performed by a member of the Reserves or the National Guard of any State. 38 C.F.R. § 3.6(d). 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 service. 38 U.S.C. §§ 1110; 1131; 38 C.F.R. § 3.303 (a). 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). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009). The Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds persuasive or unpersuasive and provide the reasons for its rejection of any material evidence favorable to the claimant. Kahana v. Shinseki, 24 Vet. App. 428, 433 (2011). This includes weighing the credibility and probative value of lay evidence against the remaining evidence of record. See King v. Shinseki, 700 F.3d 1339 (Fed. Cir. 2012). A Veteran bears the evidentiary burden to establish all elements of a service connection claim, including the nexus requirement. Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). In making its ultimate determination, the Board must give a veteran the benefit of the doubt on any issue material to the claim when there is an approximate balance of positive and negative evidence. Id. at 1287 (quoting 38 U.S.C. § 5107 (b)). Analysis As an initial matter, the Board notes that the Appellant does not contend, and the record does not suggest, that the Veteran's heart disorder is directly or presumptively related to a period of active duty. See Robinson v. Shinseki, 557 F.3d 1355, 1361 (2008) (noting that claims which have no support in the record need not be considered by the Board as the Board is not obligated to considered "all possible" substantive theories of recovery. Where a fully developed record is presented to the Board with no evidentiary support for a particular theory of recovery, there is no reason for the Board to address or consider such a theory). The record shows that the Veteran served on active duty from January 1970 to June 1970, October 1970 to September 1976, and February 1991 to May 1991, and on ACDUTRA from June 1, 2000, to June 14, 2000; and he reported that he suffered a myocardial infarction in June 2000. In this regard, the Veteran contended that such occurred two days after his completion of a period of ACDUTRA and that it was related to the difficult training he endured during the two-week period of ACDUTRA. Thus, the appellant claims that service connection for a myocardial infarction is warranted. In some instances, an appellant may benefit from application of evidentiary presumptions. However, as is noted above, the Veteran's contentions were based on the single period of ACDUTRA immediately preceding his myocardial infarction; and the presumptions of soundness, aggravation, and, most importantly, service connection for chronic diseases do not apply to claimants, even those with Veteran status from prior periods of service, for claims based on periods of ACDUTRA. 38 U.S.C. §§ 101 (24), 1137; Smith v. Shinseki, 24 Vet. App. 40 (2010). Thus, service connection may only be considered on a direct basis. As an initial matter, the Board notes that the Veteran suffered a myocardial infarction on June 16, 2000. See Medical Treatment Record Non-Government Facility, VBMS entry dated June 21, 2015. However, the Board finds that service connection is not warranted on a direct basis as the preponderance of the evidence is against a finding of a nexus between the Veteran's myocardial infarction and the June 200 period of ACDUTRA. There are no service treatment records from the Veteran's two-week period of ACDUTRA from June 1, 2000, to June 14, 2000. Private treatment records reflect that the Veteran incurred a myocardial infarction on June 16, 2000. Specifically, a June 2000 medical record from D.W., MD, indicates that the Veteran was admitted to the emergency room on March 16, 2000, with complaints of recurrent chest pain with nausea without shortness of breath or diaphoresis. He was evaluated and recommended to have a left heart catheterization. A physician performed a "difficult atherectomy" of his 90 percent LAD stenosis. Subsequent private treatment records reflect ongoing treatment for severe coronary artery disease which was under control. The Veteran was diagnosed with adenocarcinoma of the lung in 2016, treated with lobectomy and chemotherapy which recurred in 2017. In November 2017, the cardiologist noted that the Veteran was doing well as per his coronary artery disease, and had no angina. The Veteran's death certificate lists the cause of death on January 20, 2018 as metastatic left lower lobe adenocarcinoma, with tobacco use as a contributing factor. There were no other significant conditions listed as contributing to his death. In this case, there are conflicting medical opinions in this case as to whether the Veteran's myocardial infarction was related to the period of ACDUTRA. The Veteran's treating cardiologist submitted a November 2016 medical opinion based upon review of the Veteran's medical records from June 2000 to March 2003. The cardiologist opined that the Veteran's myocardial infarction was precipitated by the extreme physical exertion in temperatures up to 112 degrees during the Veteran's two weeks of ACDUTRA. He reasoned that the physical exertion led to plaque instability, which is a precursor to myocardial infarction and that it is likely that the process leading to the myocardial infarction on June 16th, 2000, began as early as June 14, 2000, or even several days before. The Board finds the cardiologist's opinion to be of lower probative value as it relies on incorrect facts with respect to extreme physical exertion based on high temperatures. A review of the historical temperature records from the National Weather Service shows that the maximum temperatures for Fayetteville, NC, varied from 73 degrees to one day of 97 degrees, with the daily average temperatures varying from 64.5 to 83 degrees, less than the 112 degrees cited by the cardiologist. In June 2020, VA obtained a medical opinion from an examiner who reviewed the available evidence of record to include the Veteran's claims file, medical treatment records dating to the Veteran's death, and November 2016 private opinion. The examiner opined that the Veteran's death was less likely than not related to residuals of the June 16, 2000 myocardial infarction that was at least as likely as not related to his ACDUTRA from June 1, 2000, to June 14, 2000. The examiner initially noted the Veteran's death from metastatic left lower lobe adenocarcinoma as listed on his death certificate which also did not list any other conditions contributing to the Veteran's death. The examiner noted that there was no available evidence that the Veteran suffered any symptoms or prodrome symptoms of ischemic heart disease during the June 1, 2000, to June 14, 2000 period of ACDUTRA. The examiner began by pointing out that an atherectomy was used for debulking calcified lesions, which were chronic, requiring months to years to develop. The examiner specifically addressed the theory raised by the private opinion: that physical exertion during ACDUTRA may have triggered the infarction by releasing plaque. In support of the opinion, the examiner referred to specific medical literature in support to explain that triggering of a myocardial infarction by exercise usually occurred within minutes to hours of the triggering events and that the time frame was supported by research on prothrombotic states induced by hypoxia. Since the Veteran had a heavily calcified LAD with 90 percent occlusion, the physician noted that while the Veteran as likely as not had asymptomatic coronary artery disease during the ACDUTRA, there was no evidence of a myocardial infarction during the ACDUTRA, and it would not have been possible for the Veteran to have developed calcific coronary artery disease during the two-week period of ACDUTRA. The examiner explained that the heart lesion seen on the June 19, 2000 cardiac catheterization was a chronic lesion requiring longer than 13 days to develop. Furthermore, the examiner noted the Veteran's other risk factors for coronary artery disease which included chronic tobacco use and untreated hyperlipidemia. In this case, the Board assigns greater probative value to the VA examiner's opinion which was adequate, competent, and highly probative. The opinion is supported by rationale based on the Veteran's complete history and accurate facts of this case. In this case, the VA examiner provided a detailed explanation regarding the extent and severity of the Veteran's occlusion at the time of the myocardial infarction to explain the lengthy time period for the development of plaque and the immediate time period for a heart attack if plaque dislodged. The VA examiner specifically considered the private opinion and supported her opinion with medical treatises. (Continued on the next page) The Veteran asserted that his myocardial infarction was related to his ACDUTRA. As a layperson, however, the Veteran was not capable of making medical conclusions; thus, his statements regarding causation are not competent evidence. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Lay statements may be competent to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. Id; see also Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). However, cardiovascular disorders are complex disorders which require specialized training for a determination as to diagnosis and causation, and they are therefore not susceptible of lay opinions on etiology, and the Veteran's statements therein cannot be accepted as competent medical evidence. On the contrary, the Board finds that the VA examiner's probative medical opinion outweighs the lay assertions in this case. The examiner provided an articulated opinion with supported reasoned analysis specific to the Veteran explaining why the Veteran's myocardial infarction was less likely than not related to his June 2000 two-week period of ACDUTRA. There is no other evidence of higher probative value. Based on the foregoing, the preponderance of the evidence is against the claim for entitlement to service connection for myocardial infarction, the benefit of the doubt rule is not applicable, and accordingly, the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. L. Chu Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Beach, 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.