Citation Nr: 21069223 Decision Date: 11/17/21 Archive Date: 11/17/21 DOCKET NO. 18-05 184 DATE: November 17, 2021 ORDER Service connection for coronary artery disease is denied. FINDING OF FACT The Veteran's coronary artery disease did not have its onset during service and is not otherwise related to service. CONCLUSION OF LAW The criteria for service connection for coronary artery disease have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the Army from May 1967 to May 1969. This matter comes before the Board of Veterans' Appeals (Board) from a June 2015 rating decision. The Veteran testified before the Board at a hearing in February 2020. A transcript of the hearing has been associated with the claims file. In April 2020, the Board remanded the Veteran's claim to obtain medical records and obtain a VA examination regarding coronary artery disease. The claim has since been returned to the Board for review. For the reasons indicated in the discussion below, the agency of original jurisdiction (AOJ) complied with the Board's remand instructions. Stegall v. West, 11 Vet. App. 268 (1998). Service Connection Under the relevant laws and regulations, 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. Generally, the evidence must show the existence of (1) 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. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Certain chronic diseases are subject to presumptive service connection if the disease manifests to a compensable degree within one year of separation from service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Moreover, for such chronic diseases, an alternative method of establishing the second and third Shedden element is through a demonstration of continuity of symptomatology if the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309(a). 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2014). Additionally, evidence of continuous symptoms since active duty is a factor for consideration as to whether a causal relationship exists between an in-service injury and the current disorder as is contemplated under 38 C.F.R. § 3.303(a). Coronary Artery Disease The Board has reviewed the evidence of record and finds that service connection is not warranted for coronary artery disease. The Veteran asserts that his coronary artery disease is caused by service. He provided testimony regarding his claim of service connection for coronary artery disease during the February 2020 hearing before the Board. The Veteran stated that he experienced chest pain off and on during service and that shortly following separation from service he sought private medical care for chest pain. The Veteran stated that his private physician sent him to a hospital for cardiac evaluation and that he subsequently had a stent placed in approximately 1970. He stated that his heart disability eventually worsened requiring bypass surgery through VA in approximately 2010. The Board has considered the lay statements of the Veteran. Although the Veteran is competent to report his observations and to opine as to some medical matters, his contention that his current heart disability is related to in-service complaints of chest pain or is otherwise related to service relates to an internal medical process, which extends beyond an immediately observable cause-and-effect relationship and is the type of evidence that the courts have found to be beyond the competence of lay witnesses. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). During the October 1966 entrance examination, the Veteran denied experiencing pain or pressure in the chest and his heart was determined to be medically normally upon clinical evaluation. During the February 1969 separation examination, the Veteran reported experiencing pain or pressure in the chest, which the examiner noted to have occurred in the past but not in recent years, and his heart was determined to be medically normally upon clinical evaluation. In May 2000, over 31 years after discharge from service, the first evidence of a heart disability is noted in his private treatment records. The Board finds that the significant lapse in time between the Veteran's discharge and post-service medical treatment weighs against the Veteran's claim of entitlement to service connection. Regarding the Veteran's private treatment records, in May 2000 he underwent a cardiac evaluation for complaints of recurrent chest pain and shortness of breath with exertion. The Veteran reported that he experienced similar discomfort three years prior but that it did not bother him very frequently. The Veteran's physician noted that the Veteran's prior medical history included knee surgery, an arm fracture in the distant past, and cardiac catheterization in approximately 1995. Subsequently, in May 2000 the Veteran was noted as undergoing angioplasty with stent implantation resulting in zero percent residual stenosis. Regarding the Veteran's VA treatment records, in February 2002 he was noted as having stents placed in May 2000, and in August 2002 he was noted as having a diagnosis of coronary artery disease with stent placement. In June 2003, he complained of occasional chest pain with activity. In March 2009, he reported an increased frequency of chest pain with exertion. Following a cardiac evaluation, the Veteran was recommended to undergo bypass surgery, which was performed in May 2009. The Board finds that the Veteran's private and VA treatment records demonstrate that he presently suffers from coronary artery disease; however, his treating physicians do not provide an opinion regarding the etiology of his coronary artery disease, and the physicians do not provide an opinion stating that his current coronary artery disease is caused by or related to the in-service complaints of chest pain. Moreover, the Board finds that although the Veteran reported a prior stent placement in approximately 1970, during the May 2000 cardiac evaluation and subsequent stent placement the Veteran's private physicians did not note a prior stent placement in either the detailed medical history or in any procedure notes or follow-up care notes regarding the stent placement procedure. Therefore, as this evidence does not demonstrate a nexus relationship and it does not demonstrate continuity of symptoms based on the clinical evidence, it does not support the claim of service connection. In March 2021, the Veteran underwent a VA examination regarding coronary artery disease. The examiner documented that upon separation from service the Veteran reported chest pain, which was noted to be in the past but not in recent years and that the Veteran underwent angioplasty with stent placement and a heart catheterization in May 2000. The examiner diagnosed the Veteran as having coronary artery disease with a bypass graft and valvular heart disease. The examiner opined that it is less likely than not that the Veteran's coronary artery disease was incurred in or caused by service. The examiner explained that although a history of chest pain was noted upon separation, there were no entries in the STRs regarding chest pain during service. The examiner also stated that there are no medical records available for many years after separation from service; therefore, it is unlikely that the Veteran's heart problem started during service. The examiner also noted that she was unable to find records from 2015. In May 2021, the Veteran was provided an addendum VA examination opinion to specifically consider records from 2015, which the previous VA examiner was unable to find. The examiner opined that it is less likely than not that the Veteran's coronary artery disease was incurred in or caused by service. The examiner noted that the Veteran reported experiencing chest pain during the separation examination, which was determined to have occurred in the past and not in recent years. The examiner stated that this evidence indicates that the condition was acute and transitory. The examiner determined that there is no evidence that the Veteran took any pertinent medication on an ongoing basis since service to the present and determined that there is no documented evidence that the Veteran sought medical attention within a year after separation from service. The examiner also determined that there is no additional evidence to support chronicity and continuity. The examiner also noted that the Veteran reported that he was told to see a cardiologist in approximately 1971; however, the examiner stated that the history demonstrates that the Veteran had a stent placed in approximately 2000, which is approximately 31 years after separation from service. Therefore, the examiner determined that a nexus relationship cannot be established between the Veteran's coronary artery disease and service and that it is less likely than not the Veteran's in-service complaints of chest pain are related to his current cardiac diagnoses. There are no medical opinions supporting the Veteran's appeal, and the Board finds the conclusions of the March 2021 and May 2021 VA examination opinions to be sufficient to determine that the Veteran's coronary artery disease is not related to service. First, the March 2021 VA examiner specifically considered the Veteran's reported complaints of chest pain upon separation from service and noted that the evidence does not demonstrate medical treatment for the Veteran's heart disability for many years after separation from service. The examiner therefore concluded that it is less likely than not that the Veteran's heart disability started during service. Second, the May 2021 VA examiner also specifically considered the Veteran's reported complaints of chest pain upon separation from service and determined that this evidence indicates that the condition was acute and transitory. The examiner noted the Veteran's reports of treatment related to a heart disability in approximately 1971 but determined that the first evidence of post-service medical treatment related to the Veteran's heart disability is documented in May 2000 when he underwent a stent placement. Therefore, the examiner found that the evidence does not support the chronicity and continuity required to establish a nexus relationship between the Veteran's in-service complaints of chest pain and coronary artery disease. As the March 2021 and May 2021 VA examination opinions are the only medical opinions of record, and the Veteran's opinion as to the cause of his disability is not probative because he lacks the expertise to offer medical opinions relating to the cause of coronary artery disease, the greater weight of the evidence is against the claim. Therefore, the appeal is denied. MICHAEL E. KILCOYNE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Page-Nelson, 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.