Citation Nr: 21070133 Decision Date: 11/23/21 Archive Date: 11/23/21 DOCKET NO. 11-26 840 DATE: November 23, 2021 ORDER Entitlement to service connection for a cardiovascular disability (claimed as a heart attack), to include as secondary to a service-connected enucleated left eye and/or meralgia paresthetica of the right hip and/or adjustment disorder with mixed anxiety and depressed mood, is denied. FINDING OF FACT A cardiovascular disability is not shown to be causally or etiologically related to any disease, injury, or incident in service, did not manifest within one year of service discharge, and was not caused or aggravated by the Veteran's service-connected enucleated left eye and/or meralgia paresthetica of the right hip and/or adjustment disorder with mixed anxiety and depressed mood. CONCLUSION OF LAW The criteria for service connection for a cardiovascular disability to include as secondary to service-connected enucleated left eye and/or meralgia paresthetica of the right hip and/or adjustment disorder with mixed anxiety and depressed mood, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1154, 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 on active duty in the United States Army from August 1970 to February 1972. In October 2013 the Veteran testified at a hearing before a Veterans Law Judge. In February 2017, the Board issued a letter informing the Veteran that the Veterans Law Judge who conducted the October 2013 Board hearing was no longer employed by the Board. The Veteran indicated that he would like to be scheduled for a videoconference hearing before a current member of the Board. In August 2017, the Board remanded the Veteran's claim to comply with his request for a hearing. Thereafter, the Veteran failed to appear for that hearing without explanation and has not requested a new hearing. The Veteran's hearing request is therefore deemed withdrawn. See 38C.F.R.§20.704(d). The Board notes that this claim was previously before the Board in February 2014, March 2015, June 2016, and August 2018. At such time, the Board remanded the claim for further development and adjudication. The Board finds there has been substantial compliance with the Board's remand orders and no further action is necessary. See D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict, compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268 (1998)). Entitlement to service connection for a cardiovascular disability (claimed as a heart attack), to include as secondary to a service-connected enucleated left eye and/or meralgia paresthetica of the right hip and/or adjustment disorder with mixed anxiety and depressed mood, is denied. The Veteran contends that he has a cardiovascular disability (claimed as a heart attack) as a result of his service-connected enucleated left eye and/or meralgia paresthetica of the right hip. In addition, the Veteran contends that he developed a psychological disability as a result of his service-connected disabilities, which is now service-connected and that such also caused or aggravated his cardiovascular disability. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § §§ 1110, 1131; 38 C.F.R. § § 3.303 (a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § § 3.303 (d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id.; also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Where a Veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases to a degree of 10 percent within one year, from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. § §§ 1101, 1112, 1137; 38 C.F.R. § §§ 3.307, 3.309. Alternatively, when a disease at 38 C.F.R. § § 3.309 (a) is not shown to be chronic during service or the one-year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § § 3.303 (b). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § § 3.309 (a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of 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) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Furthermore, service connection may not be awarded on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability. 38 C.F.R. § 3.310 (b). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § § 5107 (b); 38 C.F.R. § § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The Veteran's service treatment records are silent for any complaints, treatment, or diagnosis of a cardiovascular disability. Furthermore, upon examination in January 1972, prior to the Veteran's discharge, there was no mention of any cardiac disabilities or any related injuries or pain. However, post-service treatment records reflect that the Veteran was subsequently diagnosed with coronary artery disease (CAD) in 2004 and suffered a myocardial infarction (MI) in 2007. In June 2015 the Veteran underwent a VA Heart Conditions examination with an accompanying disability benefits questionnaire (DBQ). The examiner noted that the Veteran was diagnosed with CAD in 2004 and suffered a MI in 2007, however he had not suffered any additional cardiac related issues since then nor had he received any stress testing or cardiac follow up due to a lack of symptoms. The examiner opined that the Veteran's condition was less likely than not a result of his any injury incurred in service. The examiner provided the rationale that after looking through the Veteran's service records, there was no evidence that the Veteran ever served in Korea or Vietnam and no other evidence of Agent Orange exposure. As the Veteran had not claimed that his cardiovascular disability was due to Agent Orange exposure and as the June 2015 examiner failed to adequately address direct service connection, an addendum opinion was requested by the Board in its June 2016 remand. In June 2016 an addendum opinion was obtained. The June 2016 examiner found that after reviewing the Veteran's records, his service treatment records were "nonspecific" and not indicative of any cardiac disability. Therefore, the examiner found that as there was such a lengthy delay between the Veteran's discharge from service and his development of a cardiovascular disability, that such disability was less likely than not related to or incurred in active-duty service. In August 2021 the Veteran underwent an additional VA Heart Conditions examination with an accompanying DBQ. The examiner noted that the Veteran was diagnosed with acute, subacute, or old myocardial infarction and CAD as well as coronary artery bypass graft in 2004. In addition, the Veteran had stents put in in 2018. The examiner opined that the Veteran's cardiovascular disabilities were less likely than not proximately due to or the result of his service-connected disabilities, to include enucleation of the left eye, left total knee replacement, adjustment disorder with mixed anxiety and depressed mood, or right lower extremity sciatica. In addition, the examiner opined that it was less likely than not that the Veteran's cardiovascular disabilities were aggravated beyond their natural progression by any of the Veteran's service-connected disabilities. The examiner provided the rationale that none of the Veteran's listed service-connected conditions have any connection to his MI or CAD. Rather the examiner noted that CAD and MI are related to hypertension, hyperlipidemia, major stress, family history and diabetes mellitus. Furthermore, the examiner found that it was less likely than not that the Veteran's CAD was proximately due to or aggravated by a disability of service origin to include any psychiatric disorder attributed to the Veteran's service-connected disabilities. The examiner provided the rationale that mental disorders are not a major contributor for CAD, rather such contributors are family history of CAD, hypertension, hyperlipids, and diabetes mellitus. Furthermore, the examiner noted that major stress events like hurricanes or death are risk factors for MI or CAD. However, stress itself has not been added to the list of risk factors. In addition, the examiner noted that he completely disagreed with the Veteran's October 2013 hearing testimony that his family physician was willing to state that the Veteran's 2007 heart attack was related to stress. The examiner noted that while stress contributes to CAD it is not recognized as a risk factor, and that while extreme stress can cause an MI, as during extreme stress cortisol surges, the accepted medical research does not support that day-to-day stress causes CAD or MI. Throughout the appeal the Veteran has submitted statements in which he alleges that his cardiovascular disabilities are the result of his service or in the alternative secondary to his service-connected disabilities. During the Veteran's October 2013 hearing, he stated his belief again. He testified that he began experiencing depression and anxiety as a result of his service-connected eye and knee disabilities and stopped exercising and began smoking. Furthermore, he claimed that his family physician was willing to state that his stress caused or aggravated his cardiovascular disabilities. After a thorough review of the record, the Board finds that service connection for cardiovascular disabilities is not warranted on any basis to include presumptive, direct, or secondary service connection. As an initial matter, the Board finds the evidence clearly shows the Veteran has symptoms related to as well as diagnoses for cardiovascular disabilities, but as previously noted there was no report of any complaints, treatment or diagnoses related to such in service. However, the first element of service connection either presumptive, direct, or secondary has been met. Regarding presumptive service connection, the Board notes that the clinical evidence of record fails to show that the Veteran manifested cardiovascular disabilities or related symptoms within the one year following his discharge from service in February 1972. There is simply no medical evidence suggesting that this occurred. Rather the earliest record of any complaints of cardiovascular symptoms were in 2004, approximately 32 years after the Veteran's discharge. As such, presumptive service connection is not warranted. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Regarding direct service connection, the Board again notes that the Veteran's cardiovascular disabilities were not diagnosed during his military service, or as noted previously, for many years thereafter. As was noted above, the Veteran's service treatment records are silent for any complaints, diagnosis or treatment for cardiovascular disabilities, or any incident or injury related to such. As there is no credible evidence that the Veteran was diagnosed with or exhibited symptoms of cardiovascular disabilities during his military service, no examination or opinion is necessary to decide such aspect of his claim. See Bardwell v. Shinseki, 24 Vet. App. 36 (2010) (holding that VA is not required to provide a medical examination when there is not credible evidence of an event, injury, or disease in service). However, as the June 2015 VA examiner provided a partial direct service connection opinion, an adequate opinion was therefore needed and obtained in June 2016. The June 2015 examiner found that the Veteran did not have any service in Korea or Vietnam and a review of the Veteran's service records revealed no other incident or claims of exposure to Agent Orange. Therefore, he found that the Veteran's cardiovascular disability was less likely than not due to his active-duty service. The Board notes that the Veteran has not alleged herbicide exposure and he does not have the requisite service in order to qualify for presumptive or direct service connection in relation to such. The June 2016 examiner also found that the Veteran's cardiovascular disability was less likely than not incurred in or caused by his service. However, the June 2016 examiner reached his opinion as he found no evidence of complaints or injury related to cardiovascular disability or disease in service or for many years following the Veteran's discharge. As the June 2016 examiner provided sound medical explanations and rationales for his opinion, the Board finds it very probative. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Additionally, there are no contrary opinions of record. Furthermore, the contemporary medical evidence does not support a finding that the Veteran's conditions began in service or supports chronicity of such symptoms. The Veteran's post-service medical record is negative for any complaints, treatment, or diagnosis of cardiac problems until 2004. The Board acknowledges the Veteran's allegation that his disabilities began in or are the result of his service. However, he is not competent to diagnose or speak to the etiology of complex medication conditions. As fundamental elements of direct service connection, the in-service and nexus elements, are missing, the Board finds that direct service connection is not warranted for the Veteran's claim for cardiovascular disabilities. As for secondary service connection, the August 2021 examiner found that the Veteran's cardiovascular disabilities were less likely than not caused by, proximately due to or aggravated beyond their natural progression by his service-connected disabilities. As the August 2021 examiner provided sound medical explanations and rationales for his opinion, the Board finds it very probative. See Nieves-Rodriguez, 22 Vet. App. at 295; Stefl, 21 Vet. App. at 124. Furthermore, while the Veteran contended that his family physician was in support of the contention that the Veteran's stress caused his MI and CAD, no such opinion is of record. Therefore, there are no contrary opinions of record. As such, secondary service connection is not warranted. The Board has also considered the Veteran's statements that his cardiovascular disabilities are related to his service or his service-connected disabilities. In this regard, a layperson is competent to report on that of which he or she has personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). A lay person may speak to etiology in some limited circumstances in which nexus is obvious merely through observation, such as a fall leading to a broken leg. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). However, the question of causation or aggravation of cardiovascular disabilities involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. In this regard, such an opinion requires specialized knowledge of several internal bodily systems. There is no indication that the Veteran possesses such specialized knowledge. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran's opinion regarding the etiology of his cardiovascular disabilities is non-probative evidence. See Jandreau, supra; Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Moreover, the Veteran has offered only conclusory statements regarding the relationship between his cardiovascular disabilities and his service and service-connected disabilities. In contrast, the VA examiners took into consideration all the relevant facts in providing opinions. Therefore, the Board accords great probative weight to the VA examiners' opinions. Consequently, the Board finds that the Veteran's cardiovascular disabilities are not shown to be causally or etiologically related to a disease or injury incurred in or aggravated during active service and are not caused or aggravated by any of the Veteran's service-connected disabilities, to include his enucleated left eye and/or meralgia paresthetica of the right hip and/or adjustment disorder with mixed anxiety and depressed mood. Therefore, service connection for such claimed disability is not warranted. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for a cardiovascular disability. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. L. M. BARNARD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Unger, 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.