Citation Nr: 21072964 Decision Date: 12/07/21 Archive Date: 12/07/21 DOCKET NO. 16-11 999 DATE: December 7, 2021 ORDER Entitlement to service connection for a heart disability, to include arteriosclerotic heart disease (coronary artery disease (CAD)), is denied. FINDINGS OF FACT 1. A heart disability did not develop in service and is not otherwise causally related to service. 2. A cardiovascular disease was not present during the first post-service year. 3. The Veteran has not had ischemic heart disease during the claim period. CONCLUSION OF LAW The criteria for service connection for a heart disability, to include arteriosclerotic heart disease (CAD), have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1116, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty in the Air Force from December 1963 to September 1977, followed by active duty in the Army from September 1977 to January 1988. The Department of Veterans Affairs (VA) is grateful for his service. The Veteran testified before the undersigned Veterans Law Judge at a hearing conducted in January 2018. A transcript is of record. The Board of Veterans' Appeals (Board) remanded the appealed claim in April 2019. The claim now returns to the Board for further review. 1. Entitlement to service connection for cardiovascular disease, to include arteriosclerotic heart disease (CAD) The Veteran contends, in effect, that he has heart disease which is causally related to service, to include related to exposure to herbicide agents (e.g., Agent Orange) in service. Over the course of claim the Veteran's claimed disability has been variously characterized to include arteriosclerotic heart disease or coronary artery disease (CAD). In general, service connection may be granted for a disability or injury incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. To prevail on a direct service connection claim, there must be competent evidence of (1) a current disability, (2) an in-service incurrence or aggravation of a disease or injury, and (3) a nexus between the in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). A service connection claim must be accompanied by evidence which establishes that the claimant currently has a disability. Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Simply put, service connection is not warranted in the absence of proof of current disability. The current disability requirement may be satisfied by the presence of the claimed disability at any time during the claim period. McClain v. Nicholson, 21 Vet. App. 319,321 (2007) (the requirement that a current disability be present is satisfied "when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim [...] even though the disability resolves prior to the Secretary's adjudication of the claim"). The Board must determine whether the evidence in the record, constitutes "competent evidence that the claimant has a current disability, or persistent or recurrent symptoms of disability" under new section 5103A(d)(2)(A). See also Caluza v. Brown, 7 Vet. App. 498, 504 (1995) (where determinative issue involves either medical etiology or medical diagnosis, competent medical evidence is required), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table). Where a veteran served for at least 90 days during a period of war or on or after January 1, 1947, and manifests cardiovascular-renal disease 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; 38 C.F.R. §§ 3.307, 3.309. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as opposed to merely isolated findings or a diagnosis including the word "chronic." When the fact of chronicity in service (or during any applicable presumptive period) is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303 (b). The term "chronic disease" refers to those diseases, such as hypertension, listed under section 1101(3) of the statute and section 3.309(a) of VA regulations. 38 U.S.C. § 1101 (3); 38 C.F.R. § 3.309 (a); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). For those who had active service in the Republic of Vietnam between January 1962 and May 1975, service connection for certain enumerated diseases, such as ischemic heart disease, may be based upon presumed exposure to an herbicide agent (e.g., Agent Orange). 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307 (a)(6)(iii), 3.309(e). "Service in the Republic of Vietnam" includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 C.F.R. § 3.307 (a)(6)(iii). For diseases not among the enumerated diseases for which a presumption of service connection based on exposure to an herbicide agent has been established, service connection may still be established for the disease based on exposure to an herbicide agent if the weight of the evidence of record supports a causal link to that exposure, supported by medical opinion evidence that the herbicide agent caused the disease. Combee v. Brown, 34 F.3d 1039, 1044-45 (Fed. Cir. 1994). The claimant bears the burden of presenting and supporting a claim for benefits. 38 U.S.C. § 5107 (a); Fagan v. Shinseki, 573 F.3d 1282, 128688 (Fed. Cir. 2009). In making determinations, VA is responsible for ascertaining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). At the January 2018 hearing before the undersigned, the Veteran testified that he had a heart attack while stationed in Germany after being stationed in Vietnam, and that he was told while at Fort Campbell in 2010 that he had had a heart attack while stationed in Germany. The Veteran added that he had a test on his heart and was told that he had a 50-percent blockage, and that he had another test done at Fort Campbell Hospital which showed that part of his heart was dead, and he was then asked when he had a heart attack. Also at the hearing, the Veteran testified to questions of being in Vietnam or being exposed to herbicide agents at the perimeter of Air Force bases in Thailand in 1966 to 1967. However, the Board need not reach the question of in-service exposure or presumed exposure to herbicide agents in this case because the Board finds that the weight of the evidence does not support the presence of ischemic heart disease, which is the heart disability which may be presumptively service connected based on exposure or presumed exposure to herbicide agents. In the April 2019 remand, the Board noted that the Veteran was diagnosed with CAD in 2003, and that CAD is listed under the Veteran's past medical history in treatment records, but that there was not a current diagnosis of CAD. As discussed below, medical records and the VA examination in February 2021 have resulted in a diagnosis of non-obstructive (or non-occlusive) coronary artery disease. This is relevantly distinguished from CAD which is obstructive in nature, since ischemic (coronary obstructive) heart disease may be presumptively service connected based on exposure to herbicide agents, but non-obstructive CAD may not. Service treatment records do not show confirmed medical diagnosis or treatment for a cardiovascular disease. Rather, presenting symptoms including of chest or abdominal pain on many occasions in service were medically assessed, diagnosed, and treated as of gastrointestinal origin. Tests, scans, examinations, treatments, and hospitalizations in service supported these assessments and diagnoses. A review of several relevant service records follows. A July 1966 upper gastrointestinal examination resulted in an assessment of pelvic inflammatory disease of the duodenal bulb. A January 1973 upper gastrointestinal examination assessed a "[s]mall sliding direct hiatus hernia" and a "[p]ossible prepyloric ulcer." A September 1978 "esophagram" and upper gastrointestinal examination report informs "esophagogastric junction was patulous and this patient probably has acid reflux." "[M]arked spasm at the apex of the [duodenal] bulb" was also observed, though without definite ulceration. A December 1978 service treatment record noted a history of "hiatus hernia" with heart burn upon lying down, gagging after coughing, and waking up at night, and a past history of symptoms in 1971. The Veteran reported improvement upon treatment with Tagamet and Maalox. A February 1984 health screening noted risk factors for cardiovascular disease including positive family, history, cigarette use, and age. However, the Veteran was noted to be "asymptomatic for cardiopulmonary disease," with an active lifestyle which included running that was curtailed recently due to arthralgias in the knees. Heart examination revealed regular rate and rhythm without abnormal sounds or murmurs. An EKG was normal. A March 1984 exercise stress EKG test was assessed as "normal exercise response." In October 1985, the Veteran was seen for symptoms of burning, substernal chest pressure and pain which occurred especially at night when supine and occasionally associated with a foul taste and regurgitation. The Veteran was noted to have "never had any cardiac sounding chest pain," and to experience no chest pain with exertion. The Veteran's chest was clear and cardiac examination was normal. Extremities had good distal pulsations without clubbing, cyanosis, or edema. He was noted to smoke one to one-and-a-half packs per day. Assessments were "Doubt atherosclerotic heart disease," and, "Smoker." In both July 1982 and August 1985 reports of medical history, the Veteran indicated histories of shortness of breath and pain or pressure in the chest. However, the July 1982 report clarified that these occurred occasionally both with and without exercise, and the August 1985 report explained in a physician's notes that the chest pain was due to hiatal hernia and that the experienced shortness of breath occurred with this upper gastrointestinal-associated pain. A history was also noted of hernia at age 42 with hospitalization for hernia in 1983 at Fort Campbell Hospital. In October 1985 the Veteran underwent a Bruce protocol treadmill electrocardiogram stress test to rule out atherosclerotic heart disease. The test results were assessed as normal with good exercise tolerance. The Veteran was cleared for over-40 qualification by cardiac standards. A March 1987 hospitalization record diagnosed "chest pain secondary to acid peptic disease." A March 1987 service treatment while stationed in Germany (as informed by the detail that the Veteran was transported by a German ambulance) documents the Veteran's complaint of burning chest pain for which he was transported to a hospital, but which an April 1987 follow up treatment characterized as symptoms of heartburn, and that he continued to have such symptoms both with exertion and at rest. Follow-up examination was within normal limits. The assessment were probable gastrointestinal etiology and no cardiovascular disease. The Veteran was referred for an upper gastrointestinal examination. A further follow-up in April 1987 noted that the Veteran's symptoms of abdominal and chest pain were much improved with Tagamet. A June 1987 upper gastrointestinal examination report, upon referral due to abdominal and chest pain, provided findings of hiatal hernia with gastroesophageal reflux as well as a partially deformed duodenal bulb probably due to ulcerative disease. In an undated cardiac risk assessment within the Veteran's service treatment records, when the Veteran was 47 years of age, it was noted that the Veteran exercised for one hour, five times per week. Cardiac review noted no anginal-type chest pain, no dyspnea on exertion, no syncope, no precordial palpitations, no history of myocardial infarction, and no history of hypertension (diagnosed or treated in the past). Current medication consisted of Tagamet. A family history was noted of his mother dying of a heart condition. Records reflect that the Veteran was born in October 1940, and hence this examination was conducted in 1987 or 1988, proximate in time to the Veteran's January 1988 separation from service. Private medical records added to the claims file in March 2014 include a cardiac ultrasound examination in 2007 which was normal. A December 2019 VA heart disease examination noted the Veteran's history of non-cardiac chest pain in service in 1988 when the Veteran "was evaluated by cardiology and was completely cleared of any cardiac condition in 1988." The examiner found that the Veteran had never been diagnosed with a heart condition, and that the Veteran had no heart condition which was generally within the accepted medical definition of ischemic heart disease. The examiner also noted that the Veteran had not had a myocardial infarction, congestive heart failure, arrhythmia, heart valve conditions, infectious heart conditions, or pericardial adhesions; and that the Veteran did not require continuous medication for control of a heart condition. The Veteran had also not had any surgical or non-surgical procedures for a treatment of a heart condition, and had not been hospitalized for treatment of a heart condition. Physical examination revealed a heart rate of 60, regular rhythm, normal heart sounds, no jugular-venous distension, clear auscultation of the lungs, normal peripheral pulses including dorsalis pedis and posterior tibial, no peripheral edema, and blood pressure of 119/77. The examiner also found no other pertinent physical findings, complications, conditions, signs, or symptoms related to cardiovascular conditions. There was also no evidence of cardiac hypertrophy or of cardiac dilatation. Chest x-rays from May 2017 were noted to be normal. Regarding a METs score, upon interview-based testing, the Veteran denied any symptoms attributable to a cardiac condition with any level of activity. The examiner further found that an echocardiogram was unnecessary and an inefficient use of limited resources based on the above history and findings. A February 2021 echocardiogram revealed normal atria and ventricles, and heart valves showed no regurgitation. Left ventricular ejection fraction was 55-60 percent. A reversal of E/A ratio was suggestive of a diastolic dysfunction of the left ventricle. A February 2021 VA heart disease examination noted the Veteran's self-reported symptoms of shortness of breath, occasion chest pain, and passing out. The Veteran reported that as a result of these symptoms he was 'unable to run or do stairs.' The Veteran reported that the condition began Germany in 1997. A medical history was noted of having perceived chest pain for which he was taken to a field hospital, but was told that it was anxiety and not a heart attack. The Veteran reported that he took medication for blood pressure, and that he suffered from 'bad' acid reflux with chest burning and pain. The February 2021 examiner diagnosed non-obstructive coronary artery disease, and found that the Veteran's heart condition was not ischemic heart disease. Another vascular condition noted to be present was hyperlipidemia. The February 2021 examiner noted that possible ischemia was noted on a nuclear medicine study in March 2015, but she explained that this possibility was ruled out as a "false positive" by a follow-up cardiology examination in May 2016, when cardiac catheterization, the "gold standard" for evaluation for obstructive coronary artery disease, was conducted. The cardiologist in May 2016 could identify no objective evidence of a past myocardial infarction. Further, there catheterization was "negative for clinically significant blockage," and "only significant for non-obstructive coronary artery disease." The February 2021 examiner added that there was no objective evidence of a diagnosed heart condition prior to April 2015. The February 2021 examiner also noted, "Current echocardiogram is essentially normal with a normal ejection fraction and normal wall motion and thickness and no defect indication a previous [myocardial infarction]." The February 2021 VA examiner concluded that she could identify no objective evidence of a myocardial infarction. She opined, with consideration of the Veteran's self-reported history, current examination, and review of medical records, that the currently diagnosed non-obstructive coronary artery disease was not at least as likely as not (less than 50 percent probability) incurred in service, including based on any exposure to herbicide agents in service. Upon VA heart disease examination in August 2021, the examiner noted that the Veteran had been diagnosed with non-obstructive coronary artery disease. The examiner observed that the Veteran was evaluated and treated in service for intermittent chest pain which was found to be benign. He was cleared by cardiology in 1988, with assessed acid indigestion treated with prescribed Tagamet. The examiner noted that the Veteran's (current) dyspnea on exertion was attributable to his chronic obstructive pulmonary disease (COPD) and thus not of a cardiac origin. A history of smoking was also noted. The examiner noted that while there was a note in a May 2016 treatment record of myocardial infarction, it was "unclear how this was diagnosed." The August 2021 VA examiner explained that ischemic heart disease is disease caused by narrowing of coronary arteries which supply blood to the heart muscle, with ischemia characterized by inadequate blood supply. The examiner noted that the Veteran has not been diagnosed with ischemic heart disease, with the diagnosed condition rather being non-obstructive coronary artery disease. The August 2021 VA examiner reviewed service and post-service records and concluded, in effect, that it is not at least as likely as not (less than 50 percent probability) that the Veteran's non-obstructive coronary artery disease developed in service or was causally related to service, because the record from service reflected non-cardiac chest pain and no heart disease, and heart disease was also not shown within the first post-service year. The Veteran's testimony about a history of heart attack (myocardial infarction) and being told of medical findings of part of his heart being dead appear entirely unsupported by objective findings within medical records from service or following service, with the exception of the unexplained and medically unexplained notation of a myocardial infarction in a May 2016 treatment record, which notation is unsupported by the balance of the record and was essentially discounted by the August 2021 examiner based on the absence of any findings or medical record supporting a past myocardial infarction. This notation in the May 2016 treatment record was thus most likely either a mis-statement in the medical record or based on the Veteran's own erroneous self-report of medical history, consistent with the Veteran's testimony of medical history including of being told part of his heart was dead and that he had had a heart attack in the past, which testimony is also unsupported and generally contradicted by the balance of the medical record reflecting no history of any finding of heart attack or any finding of part of the heart being dead. The Board finds the Veteran's self-reported history of being told of a past heart attack or of part of his heart being dead are considerably outweighed by the findings and conclusions of the February 2021 VA examiner, who carefully reviewed tests and studies to rule out any past heart attack. The Veteran, as a layperson, is not qualified to address the presence or absence medical conditions not subject to lay observation. The Veteran has not been shown to possess the requisite expertise or knowledge to address these questions. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011). Hence, the Veteran's statements and testimony may not themselves serve as support for the presence of ischemic or other heart disease, which are not subject to lay observation. His statements rather only support lay observations and lay-recollected history, such as the presence of chest pain, which in this case has been medically attributed to gastrointestinal causes. While the Veteran has reported of what he recalled having been told by medical professionals, such memories may be fallible or otherwise subject to mistaken confabulation due to the passage of time or mistaken conflation of what was heard or read about. Neither service nor post-service records include assessments based on objective findings of heart attack or ischemic heart disease or obstructive coronary disease. Based on the absence of any corroboration by medical findings, including negative findings for cardiovascular disease other than non-obstructive coronary artery disease upon VA examinations and other cardiac examinations including EKG and ultrasound, the Board concludes that the weight of the evidence is against the Veteran having had a heart attack in the past and against his having ischemic heart disease during the claim period. The non-obstructive coronary artery disease as diagnosed by the February 2021 VA examiner has not been medically linked to service, and that examiner found that the Veteran did not have a heart disease linked to service. The Board finds that the balance of the evidence of record is substantially consistent with and supportive of the December 2019, February 2021, and August 2021 VA examiners' findings and conclusions, and hence the Board finds the preponderance of the evidence against onset of a heart disease in service, is against a causal link of any heart disease present during the claim period to service, and is against a cardiovascular disease being present within the first post-service year. This is supported by service records reflecting objective findings of upper gastrointestinal disease including hiatal hernia with gastric reflux to which chest pain symptoms were attributed, and negative findings for cardiac disease. This is also supported by the absence of findings of cardiovascular disease in years proximate to service, and absence of other evidence credibly linking any current cardiovascular disease to service. Further, the weight of the evidence is against a cardiac or cardiovascular condition being present at any time during the claim period other than non-obstructive coronary artery disease as diagnosed by the February 2021 VA examiner. The reversal of E/A ratio detected on February 2021 echocardiogram attributed to a left ventricle diastolic dysfunction, was not identified by examiners as reflective of cardiac disability. The listing of myocardial infarction (MI) in a past treatment record was found by the VA examiner in August 2021 to be in error, as discounted by thorough subsequent cardiac evaluation ruling out past myocardial infarction. Because ischemic heart disease has not been present at any time during the claim period, with the weight of the evidence against, service connection for ischemic heart disease based on presumed exposure to herbicide agents is not warranted. 38 C.F.R. §§ 3.307, 3.309. Because the weight of the evidence is against any cardiovascular disability having onset in service or within the first post-service year, and is against a causal link to service, service connection is not warranted on direct or first-year-post-service presumptive bases. 38 C.F.R. §§ 3.303, 3.307, 3.309. To arrive at these determinations, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against entitlement to the service connection for a heart disability, that doctrine is not applicable. See 38 U.S.C. § 5107 (b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). L. CHU Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Schechter 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.