Citation Nr: 21072788 Decision Date: 12/06/21 Archive Date: 12/06/21 DOCKET NO. 18-41 733 DATE: December 6, 2021 ORDER Entitlement to service connection for a heart disability, to include coronary artery disease (CAD), chronic ischemic heart disease, and cardiac arrhythmia, unspecified, is granted. FINDING OF FACT 1. The evidence shows the Veteran has current diagnoses of atherosclerotic heart disease, CAD, angina pectoris, unspecified, and chronic ischemic heart disease. 2. There is an approximate balance of positive and negative evidence as to whether the Veteran's heart disease, to include CAD, chronic ischemic heart disease, and cardiac arrhythmia, unspecified, manifested during service. CONCLUSION OF LAW The criteria for entitlement to direct service connection for a heart disability, to include CAD, chronic ischemic heart disease, and cardiac arrhythmia, unspecified, have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served in the United States Army from July 1977 to August 1997. This matter comes before the Board of Veteran's Appeals (Board) from an appeal of a December 2017 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In a March 2020 letter, the Veteran waived his request for a hearing in this matter. This matter was before the Board in October 2020 and June 2021, each time being remanded, in part to obtain an adequate medical opinion. The Board finds substantial compliance with the June 2021 Board remand directives. See Stegall v. West, 11 Vet. App. 268 (1998) (holding that a remand confers on the claimant, as a matter of law, the right to compliance with the remand order); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (holding that substantial, rather than strict, compliance with remand directives is required). Service Connection The Veteran asserts that his in-service chest pains and history of high cholesterol were manifestations of his heart disease. See July 2020 Correspondence from the Veteran's representative. The Veteran reports his heart problems began during active service in the 1980s. See August 2017 Personal Statement. The Veteran has a current diagnosis of atherosclerotic heart disease, CAD, angina pectoris, unspecified, and chronic ischemic heart disease. See August 2021 VA Examination. Service connection is granted on a direct basis when there is competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. 38 U.S.C. §§ 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (Vet. App. 1990), the United States Court of Veterans Appeals stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (Vet. App. 1996) (citing Gilbert, 1 Vet. App. at 54). In this case, VA made a formal finding in September 2010 that some of the Veteran's service records appear to be lost or unavailable and indicated that future attempts to locate such records would be futile. In circumstances where the Veteran's service treatment records are destroyed or lost through no fault of the Veteran, the Board has a heightened obligation to explain its findings and conclusions and to consider carefully the benefit of the doubt rule. See O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). A review of the Veteran's service treatment records indicates a history of chest pains. In August 1977, the Veteran reported chest pains for four days after a football injury. In April 1988, the Veteran underwent an electrocardiogram after complaints of chest pain. The results indicated the Veteran had a first degree atrioventricular (AV) block. In January 1989 the Veteran was seen with complaints of intermittent chest pains for the previous six months. The Veteran described the pain as sharp and stabbing and located in the center of his chest. Several weeks later, also in January 1989, the Veteran was seen for complaints of atypical chest pains with episodes lasting 3-5 minutes each. In February 1989, the Veteran had a cardiology consult noting the 3-5 minute episodes of chest pain, and he underwent an exercise stress test revealing no arrythmias, no evidence of ischemia, and a low probability of CAD. In March of 1996, a service treatment record indicated the Veteran had high cholesterol. A December 1996 retirement examination noted a normal heart and X-ray study. However, the clinician noted a first degree AV block and high cholesterol. The Veteran denied having any heart trouble, or pain or pressure in his chest. Post-service medical records include July 2007 VA medical records showing several heart tests. The Veteran underwent a cardiolite diagnostic study which revealed "no scintigraphic evidence" to suggest ischemia or infarct of the left ventricular myocardium. See July 2007 Myocardial Perfusion Scan Notes from Fayetteville VAMC. However, a resting electrocardiogram (EKG) revealed normal sinus rhythm, first degree AV block and non-specific ST changes. See July 2007 Consult: Stress Test Result from Fayetteville VAMC. The stress EKG revealed sinus tachycardia and ischemic ST changes. Id. The comments section notes that the Veteran was "utterly asymptomatic during exercise" and "displayed excellent exercise tolerance." Id. The stress test was noted as positive. Id. In September 2007, the Veteran underwent a catheterization that revealed mild luminal irregularities with no obstructive CAD. See September 2007 Cardiology Consult Results from Durham VAMC. In December 2016, the Veteran underwent a radiological examination which revealed no scintigraphic evidence of ischemia, normal wall motion and left ventricular ejection fraction, and a clinically negative and an electrically positive treadmill stress test. See December 2016 Radiologic Examination Report from Womac AMC Ft. Bragg. However, approximately one week later, the Veteran underwent a catheterization angioplasty with stent placement to treat a critical mid-left anterior descending lesion. See December 2016 Discharge Summary from Cape Fear Valley Health System. As reported by the Veteran in his personal statement, he has been informed by his cardiologist that he is one of the "rare individuals who produces a false negative" during a traditional exercise stress test. See August 2017 Personal Statement. The December 2017 rating decision denied the Veteran's claim on the basis that the claimed condition did not occur in nor was caused by the Veteran's service. That rating decision relied upon a December 2017 VA examination, affording that examination more probative weight than the Veteran's private medical evidence, despite the fact that the VA examination only cited chest pains from 1977 and did not address at all the other in-service incidents of chest pain. See December 2017 VA examination. In August 2018, the Veteran provided a positive nexus opinion from his private cardiologist that stated while it was impossible to know from the available data when his significant coronary artery obstruction developed, it is as reasonable as not to suspect the in-service chest pains the Veteran experienced were related to the beginning of his coronary artery obstruction. See August 2018 Letter from M.C.H., M.D.. In March of 2020, the Veteran provided another letter from the same cardiologist that stated it was at least as likely as not that his CAD began while in-service with the documented symptoms he experienced. See March 2020 Letter from M.C.H., M.D.. In October 2020, the Board remanded the case with instructions for the RO obtain a new opinion which considered all of the Veteran's in-service incidents of chest pain, as well as the Veteran's private medical records and the two positive nexus opinions from M.C.H., M.D.. See October 2020 Board Remand. As a result, in April 2021, three medical opinions, all from the same doctor and written on the same day, were added to the claims file. These opinions indicated it was less likely than not that the Veteran's CAD began during service because, in part, a "good amount" of time had passed between his service and the diagnosis of CAD, the Veteran's stress tests were all normal, and there was no objective evidence to establish a nexus between the Veteran's service and his CAD. Ultimately, the Board remanded the case again in June 2021, finding these new medical opinions inadequate because they "essentially recite certain medical evidence from the Veteran's service treatment records and state, without support, that the Veteran's claims folder does not contain objective evidence supporting a link between his current coronary artery disease and his active service." See June 2021 Board Remand. In August 2021, yet another medical opinion was added to the record. This examiner opined that "[g]iven CAD wasn't diagnosed until 2016, I am unable to attribute current diagnosis of CAD to chest pain while in service." See August 2021 VA Examination. The opinion went on to state there are several causes of chest pain. Id. The Board affords very little probative weight to the August 2021 medical opinion. It effectively opines that the medical professional can't say definitively that the Veteran's symptoms in service were CAD rather than, for example, gastroesophageal reflux disease (GERD). As a result, the claims file contains both positive and negative nexus opinions which state that it is impossible to know definitively one way or the other whether the Veteran's multitudes of in-service complaints of chest pain were attributable to CAD. The Board affords very little probative weight to the December 2017 VA examination, as the examiner did not appear to consider any of the Veteran's in-service incidents of chest pain beyond 1977 and did not consider the Veteran's lay statements. The Board affords some probative weight to the three opinions from April 2021 but finds them inadequate to deny the Veteran's claim as discussed in the June 2021 Board Remand. Ultimately, the Board affords more probative weight to the Veteran's private cardiologist due to both his familiarity with the Veteran's personal medical history and his review of the Veteran's claims file. As a result, the Board finds there is at least an approximate balance of positive and negative evidence contained in the claims file. Where there is an approximate balance of positive and negative evidence, the Board affords the benefit of the doubt ot the Veteran. 38 U.S.C. § 5107; 38 C.F.R. § 3.102 With regard to the elements of service connection, the Veteran has satisfied the required showing of a current disability, as he has atherosclerotic heart disease, CAD, angina pectoris, unspecified, and chronic ischemic heart disease. See August 2021 VA Examination; 38 U.S.C. § 1110; 38 C.F.R. § 3.303. The Veteran's in-service chest pains are well-documented in his service treatment records. Thus, the second element is satisfied. See, e.g. April 1988 EKG Report. Finally, because the evidence is at least in an approximate balance of positive and negative evidence that the Veteran's chest pains in service were symptoms of a heart disability, and because the Board affords little probative value to 2021 examiner's opinion, the Board affords the benefit of the doubt to the Veteran and finds his in-service chest pains were manifestations of his CAD. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Based on the foregoing, entitlement to service connection for a heart disability, to include coronary artery disease, chronic ischemic heart disease, and cardiac arrhythmia, unspecified, is granted. K.A. KENNERLY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Maisel, S. Alexander 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.