Citation Nr: 21070799 Decision Date: 11/26/21 Archive Date: 11/26/21 DOCKET NO. 16-12 302 DATE: November 26, 2021 ORDER Service connection for a heart disability, including diastolic heart failure and atrial fibrillation, as secondary to exposure to herbicides, is denied. FINDING OF FACT The Veteran's heart disability is not associated with ischemia, and it is less likely than not (less than 50 percent probability) that the Veteran's heart disability was incurred in or caused by the Veteran's active military service, to include his exposure to herbicides. CONCLUSION OF LAW The criteria for service connection for a heart disability, including diastolic heart failure and atrial fibrillation, as secondary to exposure to herbicides, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 1137; 38 C.F.R. §§ 3.303, 3.307(a)(3), 3.309(a),(e). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the U.S. Army from June 1967 to May 1969. The matter is on appeal before the Board from a June 2015 rating decision. The Board previously remanded the issue for further development in September 2018 and September 2021. The development is completed, and the issue has returned to the Board for further adjudication. Service Connection Heart Disability The Veteran asserts that he has a heart disability that is related to his presumed exposure to herbicides while serving in the Republic of Vietnam. 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 military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection requires competent evidence showing: (1) the existence of 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, 1167 (Fed. Cir. 2004). Service connection may also be established with certain chronic diseases, based upon a legal presumption, which occurs by showing that the disorder manifested itself to a degree of 10 percent disabling or more within one year from the date of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Additionally, service connection may be established under 38 C.F.R. § 3.303(b), when a symptom or symptoms of a chronic disease are noted in service, or within a year of the date of separation from service, and when chronicity is established through a continuity of symptomatology after service. The continuity of symptomatology provision is an alternative method to establishing service connection for the specific chronic diseases listed under 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 718 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted on a presumptive basis for certain diseases resulting from exposure to an herbicide agent (including Agent Orange) for Veterans who, during active military, naval, or air service, served in the Republic of Vietnam between January 1962 and May 1975, so long as the requirements of 38 U.S.C. § 1116 and 38 C.F.R. § 3.307(a)(6)(iii) are met, and the rebuttable presumption provisions of 38 U.S.C. § 1113 and 38 C.F.R. § 3.307(d) are also satisfied. 38 C.F.R. § 3.309(e). Service in Vietnam includes the landmass and the territorial sea, which is defined as the 12 nautical miles surrounding Vietnam. See Procopio v. Wilkie, 913 F.3d 1375-1376, 1379-1380 (Fed. Cir. 2019). A review of the Veteran's record shows that he served in the Republic of Vietnam from April 1968 to May 1969. Thus, exposure to herbicides is presumed. A review of the Veteran's service treatment records (STRs) does not show any diagnoses related to any heart disabilities, nor do they reflect any complaints or treatments that may be construed to be related to a later occurrence of a heart disability. The Veteran underwent a VA examination in May 2015, at which he was noted to have a diagnosis of diastolic heart failure from 2013. An echocardiogram from August 12, 2013 demonstrated an ejection fraction of 55 percent with diastolic dysfunction with mild left ventricle hypertrophy. The Veteran's private cardiologist provided the diagnosis of chronic diastolic congestive heart failure with diastolic dysfunction and hypertensive heart disease. The VA examiner indicated that while the Veteran had a history of Agent Orange exposure, he did not demonstrate any evidence of ischemic heart disease or coronary artery disease. The examiner stated that the etiology of the Veteran's heart disabilities was likely hypertensive heart disease. An additional VA Heart Conditions Disability Benefits Questionnaire was completed by a VA examiner in September 2019. The examiner noted the Veteran to have diagnoses of congestive heart failure and hypertensive heart disease. The examiner indicated that the Veteran's heart disabilities did not qualify within the generally accepted medical definition of ischemic heart disease. The examiner stated the etiology of the Veteran's heart disabilities as natural progressions of disease with age, and risk factors as the same. The examiner explained that the Veteran carries diagnoses of diastolic heart failure and hypertensive heart disease, according to private cardiology records from some time ago. He has never had diagnostic testing that would prove true coronary artery disease/ischemic heart disease. Hence, the comments from the 2015 VA examiner are correct. He has not met the criteria for diagnosing true ischemic heart disease/coronary artery disease, for the purposes of herbicide exposure. His diagnoses are not consistent with current guidelines related to herbicide exposure residuals, and any etiologies of these have not been pursued by his providers. He has never had a cardiac catheterization, nor a Lexiscan, nor other testing to determine whether he truly and specifically has underlying ischemic heart disease. Granted, in his general age group/standardized risk factors/family history, most Americans will have some level of underlying atherosclerotic disease. However, in this specific Veteran, testing and comments and visits have never mentioned true ischemic heart disease or coronary artery disease. Additionally, the examiner provided information from the Mayo Clinic showing many causations of underlying heart failure, which will not be recounted here. The examiner reiterated that the Veteran's cardiology visits from years past made no mention of true ischemic heart disease/coronary artery disease, nor have any mentions occurred since his cardiology consultations. There were no current or past entries in the Veteran's record of ischemic heart disease or coronary artery disease. Thus, the examiner opined that it was less likely than not that the Veteran's heart disorder was directly related to his exposure to herbicides because the Veteran did not have diagnoses related to ischemic heart disease or coronary artery disease. A further review of the Veteran's VA and private treatment records does not show any current diagnoses of heart disorders that may qualify as ischemic heart disorders during the appeal. As previously noted, the Veteran's private treatment records show that he underwent an echocardiogram in August 2013, and was diagnosed with chronic diastolic heart failure and hypertensive heart disease. In March 2021, the Veteran was admitted to a VA medical center for new onset atrial fibrillation. The Veteran was noted to have recently undergone outpatient NM perfusion scan that did not show evidence of ischemia. Further review of the Veteran's VA and private treatment records does not provide any indications that the Veteran's heart disabilities are associated with ischemia. As the Veteran has not been shown to have heart issues that are associated with ischemia, his heart issues are not entitled to presumptive service connection due to herbicide exposure. 38 § C.F.R. 3.309(e). Nevertheless, even when a Veteran is not found to be entitled to a regulatory presumption of service connection for a given disability, the claim must nevertheless be reviewed to determine whether service connection can be established on another basis. See Combee v. Brown, 34 F.3d 1039, 1043-44 (Fed. Cir. 1994). Pertaining to direct service connection, as previously noted, the Veteran's STRs do not show a diagnosis related to a heart disability, nor do they reflect any complaints or treatments that may be construed to be related to a later occurrence of a heart disability. The Veteran has not submitted any objective medical evidence or medical treatises that would support, or even suggest, a correlation between herbicide exposure and his later heart disabilities. The first notations in the Veteran's medical treatment records that relate to the Veteran's heart disabilities pertain to the echocardiogram the Veteran underwent in August 2013. The Veteran was diagnosed with chronic diastolic heart failure and hypertensive heart disease. The Veteran was admitted for new onset atrial fibrillation in March 2021. Thus, the earliest notations for any heart disabilities occur almost 44 years after the Veteran separated from active military service. Also, an additional VA medical opinion was obtained in September 2021, in which the VA examiner opined that it was less likely than not (less than 50 percent probability) that the Veteran's diastolic heart disease and atrial fibrillation were incurred in or caused by the Veteran's active military service, to include his exposure to herbicides. The examiner explained that there is no evidence in medical literature that suggests that exposure to herbicide agents such as Agent Orange causes diastolic heart disease and atrial fibrillation. Diastolic heart disease and atrial fibrillation are typically caused by hypertension, advanced age, coronary artery disease, or obesity. Based upon review of the Veteran's medical record, the Veteran's heart disorder, to include diastolic heart disease and atrial fibrillation, are less likely than not caused by his presumed exposure to herbicide agents such as Agent Orange. Consideration is given to the Veteran's contention that his claimed heart disability was caused by exposure to herbicides. While lay persons are competent to provide opinions pertaining to certain medical issues, the etiology of a heart disability, as is specific to this case, is outside the realm of common knowledge for someone, such as the Veteran, who does not possess medical training, specialized expertise, or experience. Jandreau v. Nicholson, 492. F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The Veteran is competent to report his symptoms, however, no probative value shall be assigned to his assertions pertaining to the diagnosis or etiology of any heart disorder. Accordingly, service connection for a heart disability, on either a presumptive or a direct basis is not warranted, and the claim is denied. MATTHEW W. BLACKWELDER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Lutgens-Staley, 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.