Citation Nr: 21074239 Decision Date: 12/14/21 Archive Date: 12/14/21 DOCKET NO. 17-06 939 DATE: December 14, 2021 ORDER Entitlement to service connection for a heart disability, to include hypertension, a heart murmur, and Mobitz type I second degree atrioventricular block, is denied. FINDINGS OF FACT 1. The Veteran's heart disability, to include hypertension, a heart murmur, and Mobitz type I second degree atrioventricular block, clearly and unmistakably preexisted the first period of active duty and was clearly and unmistakably not aggravated beyond the natural progress of the disease during the first period of active duty. 2. The Veteran's heart disability, to include hypertension, a heart murmur, and Mobitz type I second degree atrioventricular block, clearly and unmistakably preexisted the second period of active duty and was clearly and unmistakably not aggravated beyond the natural progress of the disease during the second period of active duty. 3. The Veteran's heart disability, to include hypertension, a heart murmur, and Mobitz type I second degree atrioventricular block, clearly and unmistakably preexisted the third period of active duty and was clearly and unmistakably not aggravated beyond the natural progress of the disease during the third period of active duty. 4. The Veteran's heart disability, to include hypertension, a heart murmur, and Mobitz type I second degree atrioventricular block, did not have its onset during the fourth period of active duty and is not otherwise related to the fourth period of active duty. CONCLUSION OF LAW The criteria for service connection for a heart disability, to include hypertension, a heart murmur, and Mobitz type I second degree atrioventricular block, have not been met. 38 U.S.C. §§ 1110, 1111, 1131, 1153, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.306. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran had a period of active duty for training (ACDUTRA) from September 1990 to January 5, 1991. She also had periods of active service from January 8, 1991 to May 1991, October 1992 to March 1997, and from July 1997 to June 2000. In August 2021, the Board of Veterans' Appeals (Board) remanded the Veteran's service connection claim for a heart disability along with other claims. The Regional Office granted service connection for the Veteran's pending claims of a left hip disability and bilateral pes planus with plantar fasciitis in April 2021 and September 2021 rating decisions. These are full grants of the Veteran's service connection claims for a left hip disability and bilateral feet disabilities. Therefore, these claims are no longer before the Board. Additionally, the Board has construed the Veteran's two claims for entitlement to service connection for heart murmurs and entitlement to service connection for Mobitz type 1 second degree AV block into one broader claim for entitlement to service connection for a heart disability. Clemons v. Shinseki, 23 Vet. App. 1, 5-8 (a claim is not necessarily limited in scope to a single or particular diagnosis and should be construed based on the reasonable expectations of the non-expert, self-represented claimant, and the evidence developed in processing that claim). Entitlement to service connection for a heart disability, to include hypertension, heart murmur, and Mobitz type I second degree atrioventricular block. The Veteran asserts that her heart disability is related to service. Specifically, she stated in an August 2019 statement and her December 2019 VA Form 9 that her heart murmur was diagnosed while in service. She stated that she did not have a diagnosis of a heart murmur prior to service, and she believes the second-degree AV block was closely caused or related to the heart murmur. The Veteran stated that with having her heart disability, it affects her working as at times she is out of breath easily. She also stated that she gets fatigued, and the heart palpitations cause her anxiety. Additionally, she stated that her heart murmur and second-degree AV block are not intermittent and they do not just go away. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a veteran must show: (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. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). 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 service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Additionally, where a veteran served 90 days or more of active service, and certain chronic diseases, such as hypertension, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309(a). Every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the claim for service connection for a heart disability. The reasons follow. As to evidence of a current disability, the evidence of record shows that the Veteran has been diagnosed with a Mobitz type I second degree atrioventricular block in a November 2018 VA examination. Therefore, the facts establish that the first element of a service-connection claim is met. The Veteran has had four periods of active duty, which are from September 1990 to January 5, 1991, January 8, 1991 to May 1991, October 1992 to March 1997, and from July 1997 to June 2000. The evidence shows that the Veteran noted she had high or low blood pressure and specified she was told she had high blood pressure in the August 1990 Report of Medical History. Thus, the Board will consider whether the presumption of soundness is applicable, and if so, whether it has been rebutted, as the August 1990 Report of Medical History raises the issue of whether the Veteran is entitled to the presumption of soundness for the four periods of active service. The Board is mindful that in order to rebut the presumption of soundness, there needs to be clear and unmistakable evidence that the disease or injury both existed prior to service and was not aggravated during service. a. September 1990 to January 5, 1991 and January 8, 1991 to May 1991 Initially, it must be noted that there is no formal induction examination at the time the Veteran entered active service in September 1990 and again in January 1991; however, she completed a Report of Medical History on August 30, 1990, where she described her health as good and noted that she was told she had high blood pressure one year ago. Without an examination, the presumption of soundness does not attach for that period of active duty. 38 U.S.C. § 1111 ("Every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service.") (Italics added.). Thus, the Veteran's heart is not presumed sound as she entered the first period of active duty in September 1990 and again when she entered the second period of active duty in January 1991. A pre-existing injury or disease will be considered to have been aggravated by active military, naval, or air service, where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C. § 1153. Aggravation is not conceded, however, where the disability underwent no increase in severity during service based on all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(b). Accordingly, the only benefit that can be awarded for a heart disability for the first and second periods of active duty is service connection on the basis of aggravation of the pre-existing heart disability. Independent medical evidence is needed to support a finding that the pre-existing heart disability increased in severity in service. The question of whether there has been an increase in disability during service must be answered in the affirmative before presumption of aggravation attaches, so that presumption is unaffected by the rule on service connection for increase in disability during service. The Board has gone through the service treatment records from the Veteran's first period of active duty for training (ACDUTRA), as well as her second period of active duty, and the records surrounding those time periods and finds that they do not show an increase in the severity of her heart disability during those periods of active duty. For example, the service treatment records do not document complaints, symptoms, diagnosis, or treatment related to a heart disability during her first or second period of service. In the August 1990 Report of Medical History, the Veteran reported that she denied having or ever having palpitation or pounding heart, heart trouble or murmur, and that she did not know if she had high or low blood pressure. As mentioned above, the Veteran indicated that she was told she had high blood pressure a year prior to the Report of Medical History. The January 1991 Report of Medical History shows that the Veteran denied having or ever having palpitation or pounding heart, heart trouble or murmur, or high or low blood pressure. Then, in the March 1991 Report of Medical History, the Veteran reported that she had high or low blood pressure. The Board notes that the Veteran did complain of chest pains during these periods of service, and she was diagnosed with costochondritis. The Veteran has been service connected for the costochondritis. The evidence of record shows that the Veteran is not contending that her heart disability is secondary to her service-connected costochondritis and the preponderance of the evidence shows that the costochondritis is not related to the Veteran's current heart disability. Accordingly, the preponderance of the evidence is against a finding that the Veteran's pre-existing heart disability was aggravated during her first or second period of active duty for training. Additionally, in October 2020, following an in-person examination, a VA examiner found that the Veteran's heart disability, which clearly and unmistakably existed prior to service, was not aggravated beyond its natural progression by an in-service injury, event, or illness. The examiner noted that a review of available medical records is insufficient to establish a pre-service cardiac condition as no chest pain or a heart murmur were documented upon enlistment other than self-reported hypertension. Although the Veteran had recurrent complaints of chest discomfort, all cardiac evaluations were negative, and the complaints were diagnosed as costochondritis in 1991 or as associated with GERD. The examiner found no consistent heart murmur throughout service or in the Veteran's post-service records to support a plausible aggravation of a heart condition. Furthermore, the examiner found no documented heart murmur condition reported by the Veteran on any medical history evaluations. The examiner reviewed and found no valvular pathology on any available echocardiogram of medical record and there were no abnormal electrocardiogram was identified until 2017. Finally, the examiner stated that the 2017 abnormal electrocardiogram cannot be thought as related to the chest pains during service or solitary documentation of functional heart murmur, without any diagnostic support. As the presumption of soundness does not attach as to this disability in which the Veteran is shown to have had a heart disability prior to entrance into her first or second period of active duty, and as the evidence does not show that the pre-existing heart disability was aggravated during her first or second periods of active duty, the preponderance of the evidence is against the award of service connection for the Veteran's heart disability on an aggravation basis based upon the first and second periods of active duty. b. October 1992 to March 1997 During the Veteran's third period of service, the October 1992 Report of Medical Examination, shows that clinical evaluation of the heart was normal. Therefore, the presumption of soundness attached at the time of the Veteran's entrance for her third period of service. Within an October 1992 Report of Medical History, the Veteran indicated that she was in good health and that she had heart trouble or murmur. She circled the word "murmur." It was noted on the October 1992 Report of Medical History that the Veteran had a recent cardiology consultation in August 1992, which showed no evidence of cardiac disease. However, the Veteran was found to have a minor functional murmur during the August 1992 examination. Furthermore, the Veteran was evaluated in November 1992 in preparation for a dental surgery. The November 1992 service treatment record notes that the Veteran was previously told that she had a heart murmur and costochondritis. The examiner at that time confirmed that the Veteran had a functional heart murmur, no cardiac disease, and no cardiovascular contraindication for surgery. The October 1992 Report of Medical History and November 1992 service treatment record establishes clear and unmistakable evidence that a heart disability pre-existed the third period of active duty. The facts documented within the service treatment record are not debatable. Thus, the heart disability clearly and unmistakably existed prior to the Veteran's third period of active duty. As noted above, the Board also finds that the October 2020 VA opinion establishes by clear and unmistakable evidence that a heart disability was not aggravated during the Veteran's periods of active duty. The examiner affirmatively found that there was no evidence of an etiology for aggravation of the condition beyond its natural progression based on review of current and historical literature. There is no competent evidence to weigh against the October 2020 VA opinion. Thus, the presumption of soundness was rebutted for the third period of active duty, and service connection is not warranted based upon this period of active duty. d. July 1997 to June 2000 As to the Veteran's fourth period of active service, the Veteran was provided an examination prior to entry in June 1997. A June 1997 Report of Medical Examination shows that the Veteran was found to be clinically normal in all areas, including her heart and vascular system. Thus, the Board finds she is entitled to the presumption of soundness. However, the August 1990 Report of Medical History showing that the Veteran reported having high or low blood pressure and the October 1992 Report of Medical History showing that the Veteran reported having a functional heart murmur is clear and unmistakable evidence that a heart disability preexisted the Veteran's fourth period of active service. The Board must next determine whether, under 38 U.S.C. § 1111 and 38 C.F.R. § 3.304(b), the presumption of soundness is rebutted by clear and unmistakable evidence that a disease or injury existed prior to service and was not aggravated during service, which it finds is shown during this period of active duty. However, no evidence of record has shown that during this period of service the Veteran's heart disability was clearly and unmistakably not aggravated by service. As a result, the presumption of soundness has not been rebutted. Since the presumption of soundness has not been rebutted, the Veteran is presumed sound at entry. In the June 1997 Report of Medical History, the Veteran specifically denied having palpitation or pounding heart; heart trouble or murmur; or high or low blood pressure. The service treatment records do not otherwise support evidence of symptoms, complaints, diagnosis, or treatment related to a heart disability during this period of service. However, the service treatment records show that the Veteran was seen for multiple medical complaints, which did not include a heart disability. This evidence tends to weigh against a finding that she had a heart disability in service, as it is reasonable that she would have sought treatment for the claimed heart disability, as she did for multiple unrelated medical complaints. Thus, the preponderance of the evidence does not establish the second in-service element of a service connection claim for her fourth period of service. Additionally, since the presumption of soundness is not rebutted, the issue becomes whether there is a nexus between the current heart disability and active military service. Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). As to a nexus to service, the Veteran was first diagnosed with a Mobitz type I second degree atrioventricular block in February 2018. During that medical visit, the Veteran reported that for the past few months, she would just be sitting and suddenly feel her heart beating fast. She said that this occurred intermittently and there were no accompanying shortness of breath, dizziness, or chest pains. The Veteran was then provided a holter monitor for two weeks. As a result of the test, the Veteran was diagnosed with an atrioventricular block. As the Veteran reported having a fast heartbeat as early as 2017, which is approximately 17 years after service discharge. This is evidence that weighs against a finding that the Veteran's claimed heart disability had its onset in service. Following the February 2018 testing, the Veteran inquired with her VA physician what could have caused this heart disability. In a February 2018 email, the VA cardiology nurse practitioner responded to the Veteran that the Mobitz type I second degree AV block can occur in normal subjects without underlying cardiac pathology. The management of patients with Mobitz type I second degree AV block depends on the presence or absence of symptoms, the hemodynamic status of the patient, the response to initial therapy, and the identification of any potentially reversible causes. The VA nurse practitioner noted that the Veteran was experiencing palpitations; however, they did not correlate with any significant arrhythmia. Some of the common potentially reversible causes include certain medications, myocardial ischemia, myocarditis, and cardiomyopathies. The Board finds this February 2018 opinion from the VA cardiology nurse practitioner highly probative, as the VA cardiology nurse practitioner is familiar with the Veteran's medical history and relevant medical literature. This is evidence against a nexus between the current heart disability and service. Furthermore, the Board is mindful that upon discharge from service in June 2000, the Veteran filed an application for compensation for various disabilities, including left and right knee pain, menstrual cramps, and costochondritis. However, the Veteran did not, at that time, report having a heart disability. Additionally, the Veteran was afforded a VA examination in connection with her service connection claims, and the resulting September 2000 VA examination report shows that the Veteran's cardiovascular system was unremarkable. Additionally, the examiner noted that the Veteran's heart rhythm was regular and no murmur or gallop was noted. The Veteran had another VA examination in July 2001. At that time, the Veteran noted that she did not have a history of heart problems, angina, heart attack, congestive heart failure, rheumatic heart disease, and she did not receive any treatment for heart disease. The fact that the Veteran did not complain or seek treatment for a heart disability following her separation from service tends to establish that the Veteran did not have a heart disability at the time of the September 2000 and July 2001 VA examinations, which is less than one year following service discharge from her fourth period of active service. If the Veteran experienced symptoms of a heart disability during service or following service, and experienced them continuously since then, the Board finds it likely she would have mentioned them while discussing other disabilities that she was alleging were incurred in service. The Veteran's post-service medical records tend to show that the onset of the Veteran's heart disability was not during service. For example, the Veteran was noted to have a regular heart rhythm with no murmur or gallop during multiple medical visits (See April 2001 Family Physician Healthcare Network; July 2005 CBOC Progress Note; June 2009 CBOC Progress Note; August 2011 CBOC Progress Note; May 2012 CBOC Progress Note; November 2012 CBOC Progress Note; and June 2017 Endocrine Consult). Thus, the preponderance of the evidence is against a finding that the Veteran's heart disability was diagnosed within a year of service discharge and was not noted as chronic in service. The Veteran was afforded a VA examination in connection to her service connection claim for a heart disability in November 2018. The examiner concluded that the Veteran's current heart disability was less likely than not incurred in or caused by the complaints of heart murmur in service. The examiner made this conclusion based on the Veteran's medical record; the time gap between the discharge from active duty and the date of the diagnosis of the Mobitz 1; as well as the lack of symptoms reported by the Veteran during active duty. However, the Board found the November 2018 VA examination inadequate in the August 2020 Board decision, as the examiner did not address the Veteran's August 1990 entrance examination and it was based on an inaccurate factual premise. Thus, the Board affords no probative value to the November 2018 VA examination. The Veteran was provided with another VA examination related to her claim for service connection for a heart disability in April 2021. As a result, the examiner concluded that it was less likely than not that the Veteran's heart disability incurred in or was caused by an in-service injury, event, or illness. The examiner found a review of available medical records is insufficient to establish an in-service cardiac arrhythmia or cardiac condition, which would be a plausible etiology for the diagnosed Mobitz type I second degree AV Block. The examiner stated that although the Veteran had recurrent complaints of chest discomfort, all cardiac evaluations were negative and the complaints were diagnosed as costochondritis or as associated with GERD. The examiner reported that the medical literature supported that non-cardiac chest pain (NCCP) is recurrent angina pectoris-like pain without evidence of coronary heart disease in conventional diagnostic evaluation. The prevalence of NCCP is up to 70%. Supportive for a NCCP was the lack of consistent heart murmur throughout the Veteran's service or post service records. The examiner also found no valvular pathology on any available echocardiogram of medical record. Additionally, the examiner found no abnormal echocardiogram was identified until 2017 and cannot be thought related to the service-connected costochondritis. The Board finds the April 2021 opinion highly probative, as the examiner conducted an in-person examination, reviewed the evidence, considered the Veteran's contentions of an onset in service, and provided a rationale for her conclusion, which was based on the facts of the case and medical principles. This is evidence against a nexus between the current heart disability and service. While the Veteran has alleged that her current heart disability is related to service, she is not competent to directly link any current disability to service, as medical expertise is required. In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran's own opinion is nonprobative evidence. The Board notes the Veteran has not submitted competent evidence that supports her position. "It is the veteran's 'general evidentiary burden' to establish all elements of his claim." Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). VA "is required to reject a disability claim if the claimant fails to put forth sufficient evidence showing that he suffered an injury or incurred a disease [related to] service." Holton v. Shinseki, 557 F.3d 1362, 1370 (Fed. Cir. 2009). Thus, there is no competent evidence upon which to weigh against the negative February 2018 VA cardiology nurse practitioner and April 2021 VA opinions. (Continued on the next page) For all the reasons laid out above, the Board finds the preponderance of the evidence is against the claim for service connection for a heart disability. Thus, the benefit-of-the-doubt doctrine is not for application, and the claim for service connection for a heart disability is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. D. C. JOHNSON Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Griffin, 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.