Citation Nr: 21068238 Decision Date: 11/09/21 Archive Date: 11/09/21 DOCKET NO. 14-08 012 DATE: November 9, 2021 ORDER Entitlement to service connection for a heart condition is denied. FINDING OF FACT The Veteran's heart condition was not caused by his active duty service to include his exposure to herbicide agents. CONCLUSION OF LAW The criteria for service connection for a heart condition have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served in the United States Army from September 1969 to September 1971. In February 2018, the Board remanded the case to the Agency of Original Jurisdiction (AOJ) to clarify the Veteran's diagnosis. The November 2011 VA examiner found the Veteran did not have heart condition but a later VA treatment record in October 2012 noted "likely etiology ischemic 2/2 CAD." The case was remanded for an opinion to determine if the Veteran's heart condition was related to his service, including his herbicide agent exposure. The Veteran received a new VA examination in February 2019. However, the examiner failed to consider secondary service connection or adequately consider the Veteran's herbicide agent exposure. Consequently, the case was remanded again in June 2020 for a new VA opinion. A new opinion was provided in October 2020. The Board determined that the October 2020 opinion failed to address whether the Veteran had ischemic heart disease, as there was conflicting evidence in the record. In a May 2021 remand, the Board directed a VA examiner to identify all the Veteran's current heart conditions and provide a nexus opinion. In June 2021, the VA examiner provided an opinion detailing the Veteran's heart conditions and provided nexus opinions. His rationale was based on a review of the record and current medical literature. He also considered the Veteran's herbicide agent exposure and whether his heart condition was secondary to his service-connected PTSD. As directed by the remand, he also addressed a cardiology record finding congestive heart failure (CHF) with "likely etiology ischemic 2/2 [secondary to] CAD," as well as VA treatment records about PTSD impacting his heart. Accordingly, the Board finds there has been substantial compliance with the remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). Neither the Veteran nor his representative have raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. To establish service connection for the claimed disorder, there must be (1) evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical, or in certain circumstances, lay evidence of a nexus between the claimed in-service disease or injury and the current disability. See 38 C.F.R. § 3.303 (2021); see also Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. Second, the Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). Third, the Board must weigh the probative value of the evidence in light of the entirety of the record. A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102 (2021). When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 4 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). For veterans who served 90 days or more after December 31, 1946, the chronic diseases listed in 38 U.S.C. § 1101(3) and 38 C.F.R. § 3.309(a), including hypertension, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from active duty. 38 U.S.C. §§ 1101(3), 1112(a)(1) (2018); 38 C.F.R. §§ 3.307(a), 3.309(a) (2021). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of a service-connected disability or injury. 38 C.F.R. § 3.310(a) (2021). Secondary service connection may also be established for a nonservice-connected disability which is aggravated by a service-connected disability. In such an instance, the Veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(a) (2021); Allen v. Brown, 7 Vet. App. 439, 448 (1995). To establish entitlement to service connection on this secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a nexus between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). The nexus requirement may alternatively be satisfied if the Veteran was exposed to an herbicide agent in service and has a disease that is presumed to be associated with herbicide exposure. 38 U.S.C. § 1116(a)(2) (2018); 38 C.F.R. § 3.309(e) (2021). A veteran who, during active service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the Veteran was not exposed to any such agent during that service. 38 C.F.R. § 3.307(a). The Veteran served on the ground in Vietnam during the applicable time period. Therefore, he is presumed to have been exposed to herbicide agents. The Veteran received a VA examination in November 2011. The examiner opined that the Veteran did not have a current heart disability. Nevertheless, as noted above, an October 2012 VA treatment record documented the Veteran as possibly having ischemic heart disease. The November 2011 examination is not probative evidence. The Veteran's next VA examination was in February 2019. The examiner stated that the Veteran had congestive heart failure and persistent atrial fibrillation. These disabilities, however, were not caused by his time in service. There was no evidence of heart-related in the Veteran's service treatment records, entrance examination, or exit examination. Furthermore, his complaints of heart issues did not begin until many years after service. The examiner conceded the Veteran's herbicide agent exposure as a possible nexus to service but noted that his atrial fibrillation did not qualify within the generally accepted definition of ischemic heart disease such that it was presumptive to herbicide agent exposure. The examiner noted that the Veteran had several risk factors that could explain the etiology of his heart conditions including his age, weight, gender, and having hypertension. Consequently, the examiner opined that there was no nexus to service. The Board found this examination inadequate in its June 2020 remand and therefore it will not be assigned probative weight. His next VA examination was in October 2020. In its subsequent remand, the Board did not find the October 2020 opinions inadequate. Instead, the Board sought clarification regarding whether the Veteran had ischemic heart disease. The October 2020 examiner noted the etiologies of the Veteran's congestive heart failure, hypertension, systolic dysfunction, and atrial fibrillation. None of these disabilities were linked to the Veteran's service. The examiner noted that the development of CHF "... is complex and as a result from any functional or structural heart disorder that impairs ventricular filling or ejection of the blood to the systemic circulation to meet the systemic needs." The examiner explained that CHF is caused by "diseases of endocardium, myocardium, pericardium, heart valves, or metabolic disorders." The most common causes of systolic dysfunction were idiopathic dilated cardiomyopathy, coronary heart disease, hypertension, and valvular disease. The examiner explained that hypertension was likewise linked to multiple factors including obesity, high alcohol intake, age, genetics, and many others. Last, atrial fibrillation shared a "strong association with other cardiovascular diseases" and commonly encountered causes were age, congenital heart disease, other cardiovascular diseases, increased alcohol consumption, hypertension, endocrine disorders, genetic factors, neurological disorders such as stroke, valve disease, sleep apnea, inflammation, pulmonary embolism, and left ventricular dysfunction. Thus, the examiner determined his heart symptoms were not directly caused by service. This opinion is well reasoned and is probative evidence against direct service connection for CHF and atrial fibrillation. The examiner also considered secondary service connection. The examiner listed the many possible causes of atrial fibrillation, congestive heart failure, and hypertension based on a review of multiple medical articles and PTSD not among them. The examiner stated that a heart condition is "a separate entity entirely from the PTSD and unrelated to it. A thorough review of the medical literature failed to demonstrate a causal relationship." This explanation is probative evidence against secondary causation. Regarding aggravation, the examiner explained that because the disease entities were separate, the cardiac conditions did not aggravate PTSD beyond its natural progression. This opinion is inadequate, as it addresses the opposite of the issue on appeal. The issue is not whether the heart conditions aggravate PTSD, but instead whether PTSD aggravates the heart conditions. It will not be assigned probative weight. In a June 2021 VA opinion, the examiner clarified the Veteran's diagnoses and provided a nexus opinion. The examiner stated that the Veteran does not have documented ischemic heart disease, but as noted by the prior VA examiner, he had congestive heart failure, atrial fibrillation, and hypertension. The examiner noted that the Veteran's concentric left ventricular hypertrophy was diagnosed on a July 2011 echocardiogram. As directed by the Board's remand, the examiner specifically addressed the VA record from October 2012 that stated, "systolic CHF/ stable right now/ - likely ischemic 2/2 [secondary to] CAD." The examiner explained that, "[a] resident erroneously stated that this was likely ischemic-related despite a recent negative arteriogram (2011). It is unclear why the resident would make such an error in the face of the gold standard of cardiac diagnosis to the contrary." This is highly probative against a finding that the October 2012 note was a valid diagnosis of CAD or ischemic heart disease. The Board affords greater weight to the examiner's explanation and finds that the preponderance of the evidence is against a finding of CAD or other ischemic heart disease. The examiner also explained that psychological conditions do not cause coronary artery disease, "which is due to atherosclerosis and occlusion of the coronary vessels." Although the examiner did not opine as to whether psychological conditions can aggravate coronary artery disease, this is not prejudicial to the Veteran, because the evidence supports a finding that he does not have coronary artery disease. Therefore an aggravation opinion could not benefit the Veteran. Instead, the examiner noted that the Veteran's history of hypertension more likely than not represents hypertensive heart disease because of the concentric hypertrophy. Regarding hypertension, the examiner stated that "hypertension is not connected to remote Agent Orange exposure." The examiner acknowledged the 2018 NAS study that suggested an association between hypertension and herbicide agent exposure, and explained that the study "suggested an association but did not establish cause." The examiner concluded that the Veteran's hypertension and hypertensive heart disease/congestive heart failure were not caused by his herbicide agent exposure. The examiner further explained that atrial fibrillation is not caused by remote Agent Orange exposure and "is likely idiopathic and age-related." The examiner also noted that coronary artery disease, in the face of cardiac damage, may cause atrial fibrillation, but there was no evidence that the Veteran had coronary artery disease. Consequently, his atrial fibrillation was also not due to herbicide agent exposure because it was not caused by coronary artery disease. The examiner concluded, "[t]his point is unequivocal, as the veteran was diagnosed with atrial fibrillation in the proven absence [of] coronary artery disease." The June 2021 medical opinion is highly persuasive and well-reasoned, and the Board affords it high probative weight. Regarding whether the Veteran's heart condition was caused or aggravated by his PTSD, the examiner stated that "[t]he current, widely accepted, peer-reviewed literature has not established PTSD and related psychological comorbidities, including anxiety, depression, panic disorders, etc. as a cause of essential hypertension." The examiner explained, "[b]y definition, essential hypertension is not caused by any other condition." The examiner stated that his research returned no articles supporting a causal or aggravation link for the psychological conditions and hypertension. The examiner considered the article submitted by the Veteran noting a possible association between PTSD and hypertension and stated that it did not establish cause or aggravation but instead only concluded that further research was necessary. As requested by the Board's remand, the examiner specifically addressed whether panic attacks due to PTSD could cause the heart condition. The examiner acknowledged that certain symptoms of PTSD, including panic attacks, could temporarily raise blood pressure, "...this resolves following the batement of the stimulus and the autonomic response ('Fight or flight/White coat HTN'), and this does not constitute aggravation because it does not impact the baseline condition." Regarding the VA psychological notes, the examiner stated that the comments in them were "...broad and general and are refuted by the article, treatises, established medical knowledge and practice and the pathophysiology of the veteran[']s cardiac conditions." The examiner's rationale is highly persuasive. Regarding atrial fibrillation, the examiner stated that, "[t]here is no physiologic or anatomic mechanism by which psychological conditions can cause atrial fibrillation." Although this rationale does not separately address aggravation, it is reasonable to read this rationale citing a lack of physiological or anatomical interaction, as applying to both causation and aggravation. Even though the concepts of causation and aggravation are conceptually distinct, this does not mean that the same reasoning cannot be applied to both. The examiner was asked about both causation and aggravation and the rationale offered by the examiner makes sense in both contexts because a finding of no interaction at all encompasses aggravation, and expressly rules out aggravation. The opinion is adequate and probative against the claim. The examiner also stated there was no evidence of aggravation of his congestive heart failure beyond its natural course "due to any cause." The most probative evidence of record is the June 2021 opinion, and it is against the claim. First, the Board finds that direct service connection is not warranted because there is no evidence of any treatment or complaints for a heart condition while in service. Therefore, there is no in service incident or event to find a nexus to his current disabilities. The Veteran's only assertion regarding direct service connection is that his herbicide exposure caused his heart condition. The examiner persuasively explained why the Veteran did not have ischemic heart disease (including CAD), including with a discussion of imaging studies, and why his other diagnosed conditions were not due to herbicide exposure. Regarding hypertension, the examiner addressed the 2018 NAS study and explained why it did not support a finding that the Veteran's hypertension was due to his remote herbicide exposure. Additionally, presumptive service connection for his hypertension as a chronic disease as set forth in 38 C.F.R. § 3.309(a) is not warranted because the evidence does not show it manifested to a compensable degree within one year of his discharge from service. Regarding secondary service connection, the October 2020 and June 2021 VA examiners noted that the Veteran's heart conditions were not caused or aggravated by his PTSD. As discussed above, the October 2020 opinion provides probative evidence in favor of a finding that the Veteran's PTSD did not cause his heart conditions. The June 2021 opinion provides highly probative evidence in support of a finding that the heart conditions were not caused or aggravated by PTSD. The June 2021 examiner considered the article submitted by the Veteran noting the association between PTSD and hypertension but explained that the article did not provide evidence of causation or aggravation. The June 2021 examiner also addressed the VA psychology treatment records suggesting that PTSD impacted the Veteran's heart and explained why they did not indicate that PTSD caused or aggravated the heart conditions. Last, the Board considers presumptive service connection due to the Veteran's herbicide agent exposure. Ischemic heart disease is presumptively associated with exposure to herbicide agents. 38 C.F.R. § 3.309(e). While there is a treatment record providing evidence that the Veteran has ischemic heart disease, the June 2021 VA examiner provided a highly persuasive explanation as to why that record was incorrect. As noted above, the preponderance of the probative evidence is against the finding that the Veteran has ischemic heart disease, including CAD, such that presumptive service connection is warranted. Nevertheless, the Board must also consider direct service connection as it relates to herbicide agent exposure. The June 2021 VA opinion provided competent, credible evidence against this finding. The examiner concluded that none of the Veteran's heart conditions were caused by his remote herbicide agent exposure, explained why, and explained other potential causes for the heart conditions. (Continued on the next page) Thus, in considering all the evidence of record the Board finds that service connection for the Veteran's heart conditions is not warranted. The Veteran believes his heart condition is due to herbicide exposure or secondary to his PTSD. Determining the cause of his heart conditions involves an understanding of anatomical relationships, physiological functioning, and other internal processes not readily observable. The Veteran in this case has not been shown by the evidence of record to have medical training or skills. His lay opinion is not competent evidence. Conversely, the VA opinions are based on the training and experience of the examiners, their review of the record, and their review of the medical literature. Their opinions are thus afforded higher probative value, and as the preponderance of the probative evidence is against the Veteran's claim, service connection for his heart condition is denied. D. Martz Ames Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Brunot, 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.