Citation Nr: 21075543 Decision Date: 12/20/21 Archive Date: 12/20/21 DOCKET NO. 16-11 528 DATE: December 20, 2021 ORDER Entitlement to service connection for a heart condition (claimed as a heart attack) to include hypertension (HTN) is denied. FINDING OF FACT The Veteran's heart condition did not begin during active service, or is otherwise related to an in-service injury, event, or disease. CONCLUSION OF LAW The criteria for entitlement to service connection a heart condition (claimed as a heart attack) to include hypertension have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active duty service with the U.S. Navy from July 1976 to June 1978. This case comes before the Board of Veterans' Appeals (Board) on appeal from an August 2015 rating decision of the Department of Veterans Affairs (VA) agency of original jurisdiction (AOJ). In March 2019, the Veteran had a Board hearing before the undersigned Veterans Law Judge (VLJ). A transcript of that hearing is of record. The Board remanded the matter for development in July 2019 and February 2021. With respect to the Veteran's claims decided herein, VA has met all statutory and regulatory notice and duty-to-assist provisions. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326. Neither the Veteran nor his representative has advanced any procedural arguments in relation to VA's duty to notify and assist. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015) (holding that "absent extraordinary circumstances...we think it is appropriate for the Board and the Veterans Court to address only those procedural arguments specifically raised by the veteran...."). Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish entitlement to service-connected compensation benefits, 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-the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010). Service connection may also be granted for disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Some chronic diseases may be presumed to have been incurred in service, if they become manifest to a degree of ten percent or more within the applicable presumptive period. 38 U.S.C. §§ 1101(3), 1112(a); 38 C.F.R. §§ 3.307(a), 3.309(a). For those listed chronic conditions, a showing of continuity of symptoms affords an alternative route to service connection. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F. 3d 1331 (Fed. Cir. 2013). Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent medical and lay evidence, with due consideration to VA's policy to administer the law under a broad and liberal interpretation consistent with the facts in each individual case. 38 U.S.C. § 1154(a); 38 C.F.R. § 3.303(a). The Veteran contends that his current heart condition, to include hypertension, is related to the chest pains he had during service. Service treatment records (STRs) demonstrated that the Veteran complained of chest pain in May 1977. A December 1977 treatment record documented that the Veteran complained of dyspnea. A January 1978 treatment record noted that the Veteran was hyperventilating. An EKG was done, and an oxygen mask was applied. His blood pressure was 122/72. The June 1978 separation examination noted that the Veteran marked "yes" for chest pain, depression or excessive worry, and nervous trouble or any sort. The examiner noted that the Veteran's chest pain was related to the Veteran's anxiety. His blood pressure reading was 104/60. Post service treatment records documented that the Veteran was diagnosed with atypical chest pain, consistent with musculoskeletal strain left rib, and hypertension. On September 2015 Notice of Disagreement (NOD), the Veteran indicated that he had a heart attack while on active duty aboard the USS long Beach (CGN-9) which was the reason for his early discharge. In March 2019, the Veteran testified that he was treated in-service for a heart condition. He indicated that he had a heart attack while in-service. He noted that he had high blood pressure during service. In May 2021, the Veteran was afforded a VA HTN and heart conditions examination. He was diagnosed with high blood pressure, hypertrophic cardiomyopathy (HCC), and hypertensive heart disease without heart failure. The Veteran reported that he had high blood pressure which started in 1978. He stated that he was discharged with blood pressure medications. He reported that he had heart attack in June 1978 and saw doctors and a corpsman on his ship. He reported that his blood pressure was very high while in service and he was given medication on the ship. After service, he saw a private doctor and was told he had blood pressure problems. In 1978, he came to Oklahoma after being discharged and saw a cardiologist in Tulsa because of his high blood pressure. He noted that he continued to have blood pressure problems, but he did not have another MI. The VA examiner opined that the Veteran's claimed condition was less likely than not incurred in or caused or aggravated by service. The examiner noted that there was no nexus between hyperventilation and chest pains, and any currently diagnosed condition. She explained that chest pain and hyperventilation were not symptoms of HTN or cardiomyopathy. She noted that chest pain could have varying etiologies including of gastrointestinal origin. She specified that hyperventilation was most commonly due to stress and not a symptom of HTN. She noted that the website www.ncbi.nlm.nih.gov/pmc/articles/PMC5654557/ indicated that HCC was a genetic disorder that was characterized by left ventricular hypertrophy unexplained by secondary causes, and a non-dilated left ventricle with preserved or increased ejection fraction. She noted that the Veteran had a short history of acute chest pain while in-service and it was resolved. He did not have chronic chest pain with multiple episodes while in-service. She noted that he had an episode of hyperventilation while in-service which was resolved and could be from the result of many etiologies. She noted that he had a normal blood pressure when he was hyperventilating, his respiratory rate did not support a severe hyperventilation episode. The Veteran was not diagnosed with chronic hyperventilation syndrome while in-service. She noted that those symptoms in-service occurred on separate dates and were not sufficient to conclude that a cardiac or HTN disease existed. She explained that the medical and scientific theory would not support taking two separate symptoms to conclude that they provide the only basis for a severe disorder as hypertrophic cardiomyopathy or HTN. The service records showed one occurrence of chest wall pain that was supported. However, chest wall pain by itself was not a symptom that could be the cause of HTN or hypertrophic cardiomyopathy. The Veteran did not have any service records which supported a diagnosis of HTN or cardiomyopathy. In June 2021, an addendum opinion was obtained. The examiner noted that for better clarification epistaxis (nosebleed) was not a manifestation of any cardiovascular condition. She explained that this was well known in the medical and scientific literature. Further, there were no literature or journal articles that addressed epistasis as a risk factor for cardiovascular disease. She noted that June 1977 medical record indicated that he had occasional epistaxis, and this was nonsignificant to any physician who performed a review. His blood pressure was 128/85 which was normal and would not be consistent with cardiac disease or an acute event. The provider at that time provided an etiology for the epistaxis, indicating that is epistaxis was exacerbated by anxiety. The Veteran's blood pressure was normal during that time and showed that there was no cardiac disease. The December 1976 epistaxis was related to sinus. The December 1977 examiner noted that the specific area where the epistaxis occurred was common for nose bleeds. She noted that she addressed hyperventilating and referenced the nonspecific EKG. She explained that hyperventilating was commonly associated with an anxiety condition or the flight and fight phenomena. Hyperventilation itself had its own category of description and it was not known to be associated with chest pain. The chest pain in reference to the EKG while in-service did not show typical chest pain. Medical and scientific literature, studies and teachings distinguish atypical and typical (cardiac) chest pain. She noted that the Veteran had atypical chest pain while in-service. In April 1978 the Veteran had anxiety, depression, and claustrophobia on the ship. His records documented that he was having hyperventilation and black outs. She indicated that it would be significant speculation to try to relate this to cardiac chest pain. She explained that this would correlate with the above answer regarding the hyperventilation being nonpathologic in nature. She noted that the May 1977 record documented the Veteran had chest pain twice in the past 3 days. His pain lasted for a minute or two and an impression was for possible bursitis/arthritis. This was atypical chest pain and records showed that his blood pressure was normal (118/80). He hyperventilated in January 1978 and had a normal EKG. She noted that there was no new evidence that there was chest pain of cardiac origin, an abnormal EKG with cardiac abnormality or hyperventilation of cardiac origin that he experienced while in-service. There are no medical records or opinions indicating that the Veteran's heart condition including HTN has any causal connection to service. His post-service medical records are negative for any medical opinion linking his heart condition and HTN to his time in-service. There is nothing prior to 2012 to raise such a possibility. Although laypersons, such as the Veteran, are sometimes competent to provide opinions on certain medical questions, the specific issue in this case falls outside the realm of common knowledge of a lay person as it involves making a definitive clinical determination of the nature and etiology of the Veteran's heart condition to include HTN. See Kahuna v. Shinseki, 24 Vet. App. 428, 435 (2011). While the Veteran can describe that he experiences symptoms, he is not able to provide competent evidence as to the etiology of such. The Board notes that the Veteran reported that he had a heart attack during service. A review of the Veteran's STRs did not demonstrate that he had a heart attack during service. However, his STRs demonstrated that he had chest pains and hyperventilated during service. The Board notes that the June 1978 separation examination noted that the Veteran marked "yes" for chest pains. The examiner indicated that his chest pains was caused by the Veteran's anxiety. Chest pains may be, as discussed, a symptom of many conditions, and the Veteran's belief that they were cardiac in nature is simply not competent evidence. The preponderance of the probative evidence of record weighs against the claim of service connection. There is no reasonable doubt to be resolved in this case. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, at 1 Vet. App. 49 (1990). WILLIAM H. DONNELLY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Baxter 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.