Citation Nr: 21006965 Decision Date: 02/08/21 Archive Date: 02/08/21 DOCKET NO. 13-25 352 DATE: February 8, 2021 ORDER Entitlement to service connection for a heart disability, to include coronary artery disease (CAD) and atrial fibrillation, is denied. FINDING OF FACT The diagnosed CAD and atrial fibrillation are not related to service, to include exposure to cold temperatures. CONCLUSION OF LAW The criteria to establish service connection for a heart disability are not met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from February 1977 to November 1977. He died in October 2016 and the appellant in this case is his surviving spouse. In a May 2015 decision, the Board denied the Veteran’s claim finding no evidence of a nexus. The Veteran’s timely appealed the decision to the United States Court of Appeals for Veterans Claims (Court), and by a May 2016 Order, the Court granted a May 2016 Joint Motion for Partial Remand (JMPR), which vacated and remanded the issue to the Board for further development. In December 2016, the Board dismissed the case due to the Veteran’s death; however, after the appellant was properly substituted, in July 2017, the Board remanded the claim pursuant to the finding in the JMPR. In February 2020, the Board remanded the claim for an additional time. The case has since returned to the Board for further appellate consideration. Service Connection – Applicable Laws and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). 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). Only chronic diseases listed under 38 C.F.R. § 3.309 (a) are entitled to the presumptive service connection provisions of 38 C.F.R. § 3.303 (b). Walker v. Shinseki, 708 F.3d 1331 Fed. Cir. 2013). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In rendering a decision on appeal the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57(1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (“although interest may affect the credibility of testimony, it does not affect competency to testify”). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the claims file. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382(1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment, including by a veteran. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner’s opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. The appellant asserts that the Veteran’s heart disability is related to service. Specifically, to exposure to very cold temperatures during service. The Veteran’s exposure to cold temperatures during service is conceded. See e.g., documents titled “other” on October 13, 2020. Service treatment records showed that the Veteran was hospitalized during service with benign premature ventricular and/or premature atrial contractions that went away with tobacco cessation. His separation examination showed normal heart. With respect to the issue of a nexus, evidence in support of the claim includes November 2013 and January 2015 statements from the Veteran’s treating internal medicine physician at the VA. In the 2013 treatment record, the internal medicine physician noted that the Veteran suffered from hypothermia during active duty service, which at least as likely as not contributed to his current diagnosis of CAD and atrial fibrillation. In the 2015 treatment record, the internal medicine physician noted that the Veteran’s atrial fibrillation resulted from exposure to extreme cold conditions. The internal physician explained that body temperature dropping below freezing could cause a shock to the heart that in turn decrease blood glow and damage the electrical nerve endings that supply the ventricle to the heart. This damage was the result of hypoxia and poor circulation. Evidence against the claim includes September 2011, April 2018, October 2019, and November 2020 VA medical opinions. The September 2011 examiner who physically examined the Veteran and reviewed the claims file opined that the Veteran’s heart disability was less likely than not related to service. The examiner reasoned that the Veteran was seen in service for possible cardiac symptoms and was diagnosed with PVCs and/or PACs, both which were common arrythmias that frequently occurred spontaneously with no known cause. There was no documentation of a heart disease until 2010, at which time the Veteran was diagnosed with CAD. The examiner concluded that this was over three decades from service and as such could not be related to the findings in the service treatment records. In April 2018, the VA examiner opined that it was less likely than not that any heart disability, to include CAD and atrial fibrillation had its origin during service or was caused by any event in service. The examiner reasoned that the Veteran was hospitalized during service with benign premature ventricular and/or premature atrial contractions. The treatment record noted that those went away with tobacco cessation. The examiner further added that these conditions were common in the general population and usually result in no problems as was the case in this Veteran. The Veteran had no other follow up for a heart disability during service and his separation examination showed normal heart. The examiner added that the internal medicine physician’s statements were inaccurate and there was no evidence that the physician reviewed the service treatment records. Specifically, there was no evidence of hypothermia in service and the heart condition noted in service could not have been the cause of CAD in 2010 or atrial fibrillation in 2013. The examiner noted risk factors for CAD and atrial fibrillation, which were more likely the cause of this Veteran’s conditions. In an October 2019 opinion, a VA examiner opined that the claimed conditions were less likely than not related to service. The examiner noted that the service treatment records were silent for any evidence of CAD and/or atrial fibrillation. In this regard, the examiner explained that the evidence in the service treatment records showed that the Veteran had premature heartbeats that resolved. Such was confirmed by the separation physical that showed normal cardiac system. These premature heartbeats were common in the general population, to include individuals without structural heart disease, and were not known to cause subsequent cardiac issues. The examiner further explained that this Veteran’s CAD was not diagnosed until 2010 and atrial fibrillation not until 2013, over three decades after separation from service. This long interval made it unlikely that the military service caused the development of the heart disability. Regarding the internal medicine physician’s opinion, the examiner explained that there was no evidence of hypothermia in service, but even if such occurred, it would have had to be so severe that the body temperature in the center of the Veteran’s chest was cold enough to permanently damage the nerves in the center of his heart. This severe medical event would have had to go undocumented in the Veteran’s service treatment records, which seemed unlikely at best. Lastly, the examiner noted that a review of published peer-reviewed medical literature showed no causal link between hypothermia and the development of atrial fibrillation decades later. In a November 2020 opinion after review of the record and examination of the Veteran, the examiner opined that it was less likely than not that the Veteran’s heart disease, to include CAD and atrial fibrillation occurred in or was otherwise related to service. The examiner explained that the Veteran had an episode in service when he was observed with heart palpitations without any cardiac pathology but rather just some premature ventricular beats and atrial beats. These diagnoses in and of themselves were no signs of cardiac pathology. They are extremely common in healthy individuals and most often an incidental finding on cardiac monitoring. The examiner added that in this particular case, they did not portend any foreboding cardiac diagnosis. The examiner further reviewed the climate records from February 1977, which showed some very cold temperatures at the time. However, the examiner opined that even if the Veteran was exposed to extremely cold temperatures in service, this would have nothing to do with his current heart diagnoses. The examiner explained that this was a medically incorrect hypothesis because being exposed to cold temperatures in 1977 could not lead to CAD and/or atrial fibrillation 20 to 30 years later. In this regard, the examiner noted that the Veteran’s had risk factors of CAD, to include obesity, history of tobacco use, diabetes, hypertension, and high cholesterol. Risk factors for atrial fibrillation included hypertension, CAD, rheumatic disease, atrial enlargement, valvular heart disease, congestive heart failure, hypertrophic cardiomyopathy, congenital heart disease, and obesity, to name a few. The examiner again emphasized that there was no indication of CAD and/or atrial fibrillation during service or that he had any episode in service that could have caused these conditions decades later. On review, the Board assigns higher probative value to the VA examiners’ opinions than to the statements made by the internal medicine physician at the VA. First, there is no indication that the internal medicine physician reviewed the claims file or the Veteran’s service treatment records. There was no mentioning of the actual treatment the Veteran received in service. Second, the internal medicine physician indicated that the Veteran suffered from hypothermia; however, there is no objective evidence that such in fact occurred. Lastly, the internal medicine physician did not address the fact that the current diagnoses were not rendered until over three decades later. On the contrary, the VA examiners explained that a review of the service treatment records showed no cardiac pathology and that it would be very unlikely that such severe hypothermia would not be documented. In addition, even accepting the fact that the Veteran as in fact exposed to severe cold weather, the fact that CAD and atrial fibrillation were not diagnosed until many years later led to the conclusion that it was less likely than not related to the reported incident in service. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion). While the Veteran and the appellant are competent to describe symptoms experienced or witnessed at any given time, they are not shown to possess the necessary medical knowledge or expertise to render an opinion regarding the likely etiology of such symptoms. For the reasons and bases discussed above, the preponderance of the evidence is against the Veteran’s claim, and it therefore must be denied. Romina A. Casadei Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Yaffe, 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.