Citation Nr: 21006410 Decision Date: 02/04/21 Archive Date: 02/04/21 DOCKET NO. 10-33 513 DATE: February 4, 2021 ORDER Entitlement to service connection for symptomatic sinus node dysfunction, status pacemaker implantation (SSND) is denied. FINDING OF FACT The preponderance of the evidence does not support a finding that the Veteran’s SSND is related to an in-service event, injury, or disease or to any period of active or inactive duty for training. CONCLUSION OF LAW The criteria for service connection for SSND are not met. 38 U.S.C. §§ 101, 106, 1101, 1110, 1131 (2012); 38 C.F.R. §§ 3.303, 3.304 (2019). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had a period of active duty service from April 1981 to December 1996. He had subsequent reserve component active duty for training (ACDUTRA) from March 1998 to June 1998, and had additional periods of verified and unverified periods of ACDUTRA and inactive duty for training (INACDUTRA), including a period of apparent ACDUTRA on May 3, 2003. The Veteran purportedly separated from the Air Force Reserves on Orders issued in February 2006. In July 2016, the Veteran testified at a videoconference hearing before the undersigned. A transcript of the hearing is of record. The Board issued an appellate determination in October 2017 holding that the Veteran’s Air Force Reserves STRs during periods of ACDUTRA and INACDUTRA from February 1997 to March 2004 reveal no heart condition or abnormalities. In an August 2018 Joint Motion for Remand (JMFR), Court of Appeals for Veterans Claims (CAVC) remanded the claim noting that the Board did not consider the private treatment records covering the Veteran’s Air Force Reserve periods of ACDUTRA and INACDUTRA from February 1997 to March 2004. Particularly, the Board did not address the August 2003 private medical record reflecting that the Appellant has sinus bradycardia associated with episodes of dizziness and light-headedness which may be pre-symptoms to SSND. The Board last remanded the Veteran’s for additional development in September 2020. Specifically, the Board requested the record be delivered to a qualified examiner for an opinion as to whether the Veteran’s SSND is proximately related to his August 2004 diagnosis of sinus bradycardia associated with episodes of dizziness and light-headedness. The Board finds that there was substantial compliance with the September 2020 remand. See Stegall v. West, 11 Vet. App. 268, 271 (1998). 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. 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”—the so-called “nexus requirement.” Holton v. Shinseki 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2019); Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, a preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). Entitlement to service connection for symptomatic sinus node dysfunction, status pacemaker implantation (SSND) The Veteran contends that his SSND is related to his time in-service. The Board acknowledges that the Veteran’s treatment records reveal that the Veteran underwent the implantation of a pacemaker for SSND. However, the Board observes that the Veteran’s SSND occurred while the Veteran was a Member of the Air Force Reserves, but not under the performance of active duty, ACDUTRA, INACDUCTRA. The Board finds service connection not warranted for a SSND, because the records indicate onset of the SSND condition outside the Veteran’s period of active duty, ACDUTRA, or INACDUCTRA service and is not shown to be related to service. The Veteran’s active duty service treatment records (STR’s) confirm that upon entrance into the Airforce from April 1981 until separation on December 1996, the Veteran’s heart tested normal. During this period of service, the Veteran was regularly diagnosed and treated with medication for ongoing high blood pressure, high cholesterol, and placed on a weight loss programs. On an August 1996 examination, STR’s reveal that the Veteran was diagnosed with high blood pressure, high cholesterol, and obesity issues. In a September 1996 examination STR’s reveal that the examiner noted abnormal findings of hypercholesterolemia. August 2003 private treatment records reveal that the Veteran was diagnosed with sinus bradycardia associated with episodes of dizziness and light headedness. December 2004 STRs reveal that the Veteran was placed on limited work status due to the implantation of a pacemaker. By February 2006 the Veteran was medically discharged from service. A review of the evidence above shows that the etiology of the Veteran’s heart condition was not due to his diagnosed heat exhaustion on May 3, 2003. The Veterans STR’s above reveal that the Veteran’s examinations prior to the heat exhaustion incident revealed no heart abnormalities. The Veteran’s STR’s also reveal no SSND present after the heat exhaustion incident as a September 2003 examiner medically cleared the Veteran for deployment. March 2005 private treatment records reveal that the examiner noted that the Veteran has a history of sinus node dysfunction mild hyperlipidemia. The examiner also noted that the Veteran underwent a cardiac catheterization in October 2003. The medical examiner noted that the Veteran’s coronary arteries were without any significant obstructive disease. July 2008 private treatment records reveal that the Veteran underwent a cardiac catherization and coronary angiography procedure. July 2016 to July 2017 private treatment records reveal that the Veteran regularly underwent cardiac consults for his pacemaker. In a June 2017 VA examiner opinion to determine the etiology of the Veteran’s SSND, the examiner noted that a review of medical literature does not support the conclusion that one episode of heat exhaustion could cause SSND. The examiner noted that the Veteran was discharged the same day from the military clinic with no evidence of SSND after receiving treatment for the heat exhaustion incident. Taking into account all of the evidence the examiner opined that it is less likely than not that the Veteran’s heart disability had its onset in service or is the result of a disease or injury during the Veteran’s period of active service, ACDUTRA or INACDUTRA. In a December 2019 VA heart conditions examination, the examiner, apparently checking the wrong box, indicated that the Veteran’s claimed SSND was at least as likely as not incurred in or caused by an in-service injury. The examiner diagnosed the Veteran with SSND and an implanted cardiac pacemaker. In providing the rationale for the opinion, the examiner noted that the Veteran’s STRs were silent and there was no evidence of in-service treatment for SSND. The examiner also noted that a review of the Veteran’s separation examination dated November 1996 indicates no complaints of SSND. The examiner also noted that the Veteran’s claimed condition shows no continuity of care and was documented several years after service. Therefore, based on available records reviewed and current evaluations, the examiner conflicting with his prior opinion, opined that the Veteran’s claimed condition of SSND less likely than not incurred in or was caused by military service. In a November 2020 VA examiner addendum opinion, the examiner was asked to determine whether the Veteran’s August 2003 diagnosis of sinus bradycardia associated with episodes of dizziness and light-headedness is proximately related to or caused the onset of the Veteran’s SSND disorder. After a review of the record, the examiner noted that the Veteran was diagnosed and treated for sinus bradycardia associated with light headedness and dizziness on August 2003. The examiner determined that the Veteran’s sinus bradycardia caused the onset of his SSND. The examiner also determined that the start date of the Veteran’s SSND is August 2003. The Board also reviewed the Veteran’s lay statements, and hearing testimony asserting that the onset of his SSND is related to his time in-service. Lay people are competent to report on matters observed or within their personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Therefore, the Veteran is competent to provide statements of symptoms which are observable to his senses. However, the Board must emphasize that the Veteran is not competent to interpret accurately clinical findings pertaining to a SSND disorder as this requires highly specialized knowledge and training. 38 C.F.R. § 3.159 (a)(1) (2018). See also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The foregoing summary of the treatment record reveals no possibility for service connection for SSND. Although the Veteran contends that he experienced sinus bradycardia associated with episodes of dizziness and light-headedness which proximately caused the onset of his SSND disorder, the start date of the Veteran’s sinus bradycardia and SSND occurred on August 2003 which is outside his periods of active duty, ACDUTRA, and INACDUTRA. As noted above, in order to be granted service connection, there must be evidence of an in-service incurrence or aggravation of a disease or injury. As a pathology for the onset of the Veteran’s sinus bradycardia or SSND has not been shown to be related to service or to active of inactive duty for training, the Board concludes that the clinical evidence does not support the Veteran’s contentions for a granting of service connection. Based on this evidence, the Board finds service connection is not warranted. The Board has considered the benefit-of-the-doubt doctrine; however, the Board does not perceive an approximate balance of positive and negative evidence. The preponderance of the evidence is against the claim, the doctrine is not applicable, and the claim must be denied. 38 U.S.C. § 5107 (b) (2012); 38 C.F.R. § 4.3 (2019). MICHAEL D. LYON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Elliot Harris, 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.