Citation Nr: 21008166 Decision Date: 02/11/21 Archive Date: 02/11/21 DOCKET NO. 16-03 562 DATE: February 11, 2021 ORDER Entitlement to service connection for a heart condition, to include peripheral vascular disease and valvular heart disease, is denied. FINDING OF FACT A preponderance of the evidence is against finding that the Veteran’s heart condition, to include peripheral vascular disease and valvular heart disease, is attributable to his active service, including his in-service exposure to herbicide agents. CONCLUSION OF LAW The criteria for service connection for a heart condition, to include peripheral vascular disease and valvular heart disease, have not been met. §§ 1101, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from August 1967 to August 1969. This matter is before the Board of Veterans’ Appeals (Board) on appeal from an August 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously before the Board in November 2018 and August 2020 when it was remanded for further development. Entitlement to service connection for a heart condition, to include peripheral vascular disease and valvular heart disease, is denied. The Veteran contends his heart condition is related to his active service, including his in-service exposure to herbicide agents. 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 military 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 current disability and an in-service precipitating disease, injury or event. 38 C.F.R. § 3.303(a). For certain disabilities, such as ischemic heart disease, service connection may be presumed to be the result of in-service exposure to herbicide agents used in support of the United States and allied military operations in the Republic of Vietnam, e.g., Agent Orange, during the period beginning on January 9, 1962, and ending on May 7, 1975, specifically: 2,4-D; 2,4,5-T and its contaminant TCDD; cacodylic acid; and picloram. 38 U.S.C. § 1116; 38 C.F.R. § 3.309(e). Veterans who served in the Republic of Vietnam are presumed to have been exposed to such herbicide agents. 38 C.F.R. § 3.307(a)(6)(iii). Veterans who were otherwise exposed to those agents may also take advantage of the presumptive health effects. However, unlike Vietnam veterans, they are required to prove that they were, in fact, exposed to herbicide agents during their military service. Combee v. Brown, 34 F.3d 1039, 1043-44 (1994). That is, they do not have the benefit of a presumption of exposure as do Vietnam veterans. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded to the claimant. In this case, medical evidence of record indicates that the Veteran was diagnosed with two heart conditions. Specifically, an October 2011 VA treatment record notes a diagnosis of peripheral vascular disease (carotid stenosis). Additionally, a November 2019 VA examination report notes a diagnosis of valvular heart disease. Thus, the first element of service connection is met. Regarding an in-service incurrence, the Board concedes the Veteran’s exposure to herbicide agents in Vietnam as his service treatment records reflect that he was injured by hostile forces in Vietnam in February 1968. Additionally, his DD 214 for his period of active duty service reflects he was awarded the Vietnam Service Medal with three Bronze Star Service Stars, the Combat Infantryman Badge, a Purple Heart, and an Army Commendation Medal with V Device. Therefore, the second element of service connection is also met. The remaining issue is whether there is a nexus between the Veteran’s diagnosed heart condition and his active service. In this regard, the Board notes that there are two negative nexus opinions of record. In November 2019, the Veteran underwent a VA examination. Following examination of the Veteran, the examiner diagnosed valvular heart disease and vascular disease (bilateral carotid artery stenosis). The examiner then opined that the Veteran’s peripheral vascular disease (carotid stenosis) was less likely than not related to his active service. The examiner noted that, according to VA’s website, carotid artery stenosis is a peripheral vascular disease, which is not listed as a medical condition related to herbicide exposure. Thus, the examiner concluded that there was a lack of medical literature linking peripheral vascular disease to herbicide exposure. In October 2020, another VA medical opinion was obtained. Following a review of the medical evidence of record, the examiner noted the diagnosis of valvular heart disease and indicated that the Veteran’s condition affected the mitral valve. The examiner then opined that it is less likely than not the Veteran’s diagnosed valvular heart disease was related to his active service. In support of the opinion, the examiner noted that there was no evidence of valvular heart disease on the entrance or separation examinations and that his blood pressure readings during service were normal. The examiner also indicated that there was no evidence of chronically disabling valvular heart disease during service, any evidence of acute onset in the period leading up to his separation from service, or evidence of a condition from service that would lead to a valvular condition. Additionally, the examiner noted that the Veteran’s valvular heart disease was not related to herbicide exposure. In support of the opinion, the examiner referenced medical literature from the American Heart Association, which indicated that the mitral valve controls the flow of blood between the upper and lower chambers of the left side of the heart and when the heart is working properly, the mitral valve closes completely when the heart pumps and prevents blood from flowing back into the left atrium. However, in some people with mitral valve prolapse, one or both of the mitral valve leaflets have extra tissue or stretch more than normal, causing them to bulge like a parachute into the left atrium each time the heart contracts. The bulging keeps the valve from closing tightly and, in some cases, may cause blood to leak backward through the valve. The examiner also referenced medical literature from the Mayo Clinic, which indicated that possible causes of the condition include mitral valve prolapse, damaged tissue cords, rheumatic fever, endocarditis, heart attack, abnormality of the heart muscle, trauma, congenital heart defects, certain drugs, radiation therapy, and atrial fibrillation. The examiner then explained that environmental exposures, including exposure to herbicide agents, was not listed as a cause for the Veteran’s valve problems. The Board finds these medical opinions persuasive and highly probative as the examiners adequately explained that the Veteran’s heart conditions were not caused by his active service, to include his exposure to herbicide agents. The opinions also reflect adequate consideration of the Veteran’s medical history and relevant medical literature. Furthermore, the opinions are supported by medical evidence of record, including the Veteran’s service treatment records which do not contain any notes related to a heart condition. In light of this, the Board finds a preponderance of the evidence is against finding that there is a nexus between the Veteran’s heart condition and his active service. The Board acknowledges the Veteran’s lay statements that his heart condition is related to his in-service exposure to herbicide agents, but he is not competent to provide a nexus opinion in this case. This issue is medically complex, as it involves knowledge of internal disease processes in order to determine the medical cause of disability. See Jandreau v. Nicholson, 492 F.3d at 1377 n.4. Thus, the Board concludes the final element of service connection has not been met; therefore, the preponderance of the evidence is against finding the Veteran’s heart condition was incurred in or is otherwise related to his service. The Board finds the Veteran does not meet the criteria for presumptive service connection as the medical evidence of record fails to demonstrate the Veteran was diagnosed with a disease, including ischemic heart disease, presumed to be associated with herbicide exposure. See 38 C.F.R. § 3.309(e). As noted above, October 2011 VA treatment records indicate the Veteran was diagnosed with peripheral vascular disease (carotid stenosis). It is also noted that there is no evidence of ischemic heart disease as ischemic heart disease does not include peripheral manifestations of arteriosclerosis such as peripheral vascular disease. Additionally, the November 2019 VA examiner noted that, according to VA, carotid artery disease is a subset of peripheral vascular disease, not ischemic heart disease. The examiner also noted that the Veteran’s valvular heart disease does not meet the medical definition for ischemic heart disease. Lastly, although a July 2015 VA treatment record noted that the Veteran’s right internal carotid artery was chronically occluded secondary to atherosclerosis, an October 2020 addendum opinion clarifies that the July 2015 note does not indicate a diagnosis of ischemic heart disease. The examiner explained that the described atherosclerosis (plaque) is in the carotid artery and these blood vessels are part of the peripheral vascular system, rather than the cardiovascular system, and since the findings are not in the cardiovascular system, the condition cannot be called atherosclerotic cardiovascular disease. As such, service connection on a presumptive basis is not warranted. Consequently, the Board finds the preponderance of the evidence is against finding the Veteran’s heart condition, to include peripheral vascular disease and valvular heart disease, is related to his active service. The Board has considered the benefit-of-the-doubt rule; however, since the preponderance of the evidence is against the claim, the rule is not for application. As such, service connection is denied. M. Mills Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Jiggetts 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.