Citation Nr: 21008346 Decision Date: 02/16/21 Archive Date: 02/16/21 DOCKET NO. 15-04 739 DATE: February 16, 2021 ORDER Entitlement to service connection for atrial fibrillation, to include as secondary to left wrist tendonitis, migraine headaches, and their prescribed medications, is denied. FINDING OF FACT The Veteran’s atrial fibrillation did not manifest to a compensable degree within one year of separation from service; continuity of symptomatology is not established; and the disorder is not otherwise related to service or a service-connected disability, to include medications prescribed for left wrist tendonitis and headaches. CONCLUSION OF LAW The criteria for entitlement to service connection for atrial fibrillation are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Navy from June 1978 to October 1996. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a July 2011 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In May 2018 and October 2019, the Board remanded these matters for further development. The Veteran asserts that his atrial fibrillation is either proximately caused by or aggravated (worsened beyond natural progression) by medications prescribed for the treatment of his service-connected left wrist tendonitis and migraine headaches. See May 2011 claim, August 2011 Notice of Disagreement (NOD). Generally, 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). Establishing service connection generally requires evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Certain chronic diseases, including cardiovascular-renal disease, may be presumed to have been incurred in service if they become manifest to a degree of 10 percent or more within one year of leaving qualifying military service. 38 U.S.C. § 1112 (a); 38 C.F.R. §§ 3.307 (a)(3), 3.309(a). If there is no manifestation within one year of service, service connection for a recognized chronic disease can still be established through continuity of symptomatology. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (2013). Service connection may also be established on a secondary basis for a disability proximately due to or aggravated by a service-connected disease or injury. See 38 C.F.R. § 3.310; see also Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). To establish secondary service connection, a Veteran must show: (1) the existence of a present disability; (2) the existence of a service-connected disability; and (3) a causal relationship between the present disability and the service-connected disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). The Veteran has a current diagnosis of paroxysmal atrial fibrillation. See October 2014 VA examination report. Thus, element one of service connection is met. The Veteran does not assert, and the available evidence of record does not otherwise demonstrate that the Veteran’s paroxysmal atrial fibrillation had its onset during his active duty service or within one year of separation, and service connection on a direct basis, to include based on continuity of symptomatology and presumptively for chronic disease, fails on this element alone. However, the Veteran is service-connected for both left wrist tendonitis and migraine headaches. Accordingly, element two of service connection on a secondary basis is met. Regarding element three of service connection, or nexus, there is evidence both in favor of and against the claim. In favor of the claim are articles submitted by the Veteran and his own lay statements. In this regard, the Board has specifically considered the statements made by the Veteran relating atrial fibrillation to the medications prescribed for treatment of his service-connected left wrist tendonitis and migraine headaches. See June 2011, August 2015, August 2019, and December 2019 Veteran lay statements; June 2015, April 2015, August 2015, August 2019, and September 2019 Appellate Briefs. While the Veteran is competent to report he first experienced symptoms of his atrial fibrillation (such as heart palpitations) after taking medications for his left wrist and migraine headache disabilities, he is not competent to provide a medical opinion linking those symptoms, as such a finding requires extensive knowledge of complex medical processes and testing. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Barr v. Nicholson, 21 Vet. App. 303 (2007). Accordingly, the Veteran’s lay statements concluding that there is a nexus between the medications prescribed for his service-connected disabilities and his diagnosed paroxysmal atrial fibrillation are of no probative value. In addition to his lay statements, the Veteran also supplied medical articles that are favorable to his claim. In August 2011, the Veteran submitted “Non-steroidal anti-inflammatory drug use and risk of atrial fibrillation or flutter: population-based case-control study” published in the British Medical Journal (BMJ) dated July 2011 and an article entitled “Long-term use of Anti-Inflammatory Drugs and Risk of Atrial Fibrillation” dated 2010. Regarding the BMJ article, October 2014 and January 2020 VA examiners concluded that the study failed to identify an accepted biologic mechanism and the susceptibility of case-control studies to unmeasured confounders rendered the study unreliable regarding establishing a causal relationship between non-steroidal anti-inflammatory drugs (NSAIDs) and atrial fibrillation. The Board also notes the study itself was limited by its inability to separate paroxysmal, persistent, and permanent atrial fibrillation. See BMJ article at 4. Notably, the other article submitted by the Veteran concluded that the use of NSAIDs was associated with chronic atrial fibrillation; however, it concluded there was no association between NSAIDs and paroxysmal atrial fibrillation. The Veteran’s diagnosis is paroxysmal atrial fibrillation; thus, the 2010 article is of little probative value regarding the Veteran’s claim. In August 2015, the Veteran submitted an article entitled “FDA strengthens warning that non-aspirin nonsteroidal anti-inflammatory drugs can cause heart attacks or strokes” dated July 2015. The article is a safety announcement issued by the Food and Drug Administration recommending revised warnings on NSAID labels to warn of an increased risk of heart attack or stroke. This article is in no way specific to the circumstances of the Veteran’s medical history and in no way references the Veteran’s diagnosed disability, and is thus non-probative. Against the claim are the July 2011, October 2014, January 2019, and January 2020 VA examiners’ opinions. In July 2011, a VA examiner diagnosed atrial fibrillation and concluded that the medical evidence did not support a nexus between the Veteran’s migraine headaches (to include prescribed medications) and atrial fibrillation but failed to provide a medical rationale and is of no probative value. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (holding that a medical opinion that contains only data and conclusions is accorded no weight). The October 2014 VA examiner diagnosed paroxysmal atrial fibrillation and opined that the Veteran’s diagnosis was less likely than not due to the Veteran’s service-connected left wrist tendonitis and migraine headaches. In support of her conclusion, the VA examiner noted the Veteran had risk factors of left atrial enlargement, progressing age, obesity, family history, and obstructive sleep apnea that are associated with atrial fibrillation. In addressing the 2011 BMJ article, the October 2014 VA examiner cited to an article entitled “Epidemiology of and risk factors for atrial fibrillation” that included a review of the July 2011 BMJ article and concluded that while case-control studies have suggested a modest increased risk for the development of AF in patients taking nonsteroidal anti-inflammatory drugs, “the absence of an accepted biologic mechanism and the susceptibility of case-control studies to unmeasured confounders makes us cautious about the strength of this association.” See October 2014 VA examination report. In May 2018, the Board noted the October 2014 VA examiner failed to address the aggravation prong of secondary service connection and remanded this matter for an addendum opinion. The resultant January 2019 VA examiner noted the Veteran’s paroxysmal atrial fibrillation arose for the first time in 2006 without any symptoms on active duty. The examiner opined that the atrial fibrillation did not have its onset during active duty and was not caused by or aggravated by the Veteran’s service-connected disabilities. The January 2019 examiner concluded that the Veteran’s weight, age, gender, and family history were personal risk factors that led to the development of the Veteran’s paroxysmal atrial fibrillation. In October 2019, the Board remanded this matter once more and requested an addendum opinion to address the article submitted by the Veteran in August 2015 entitled “FDA strengthens warning that non-aspirin nonsteroidal anti-inflammatory drugs (NSAIDs) can cause heart attacks or strokes”. In January 2020, a VA medical doctor opined that the Veteran’s atrial fibrillation was less likely than not proximately caused by the Veteran’s service-connected left wrist tendonitis and migraine headaches and was at least as likely as not due to his obesity and left atrial enlargement. See January 2020 VA examination report. The January 2020 VA examiner, who reviewed the entire claims file, supported her rationale by citing to medical articles that concluded obese individuals are significantly more likely to develop atrial fibrillation than those with a normal body mass index. See “The role of obesity in atrial fibrillation,” European Heart Journal, https://academic.oup.com/eurheartj/article/37/20/1565/2570447 (last visited February 11, 2021); “Electrophysiological, Electroanatomical, and Structural Remodeling of the Atria as Consequences of Sustained Obesity,” https://pubmed.ncbi.nlm.nih.gov/26139051/ (last visited February 11, 2021); and “Weight and weight change and risk of atrial fibrillation: the HUNT study,” https://pubmed.ncbi.nlm.nih.gov/31209455/ (last visited February 11, 2021). The January 2020 VA examiner went on to explain that the primary mechanism for the role of obesity may be an increase in the size of the left atrium and supported this conclusion by citing to an additional medical journal. See “Electrophysiological and hemodynamic characteristics associated with obesity in patients with atrial fibrillation,” https://pubmed.ncbi.nlm.nih.gov/22726633/ (last visited February 11, 2021). The January 2020 VA examiner also addressed the July 2011 BMJ article and the FDA safety update provided by the Veteran. In addressing the July 2011 BMJ article, the January 2020 VA examiner concluded it was “not reliable as having established a causal relationship between NSAIDs and atrial fibrillation” and cited to research in support of this conclusion. See “Epidemiology of and risk factors for atrial fibrillation,” https://www.uptodate.com/contents/epidemiology-of-and-risk-factors-for-atrial-fibrillation (last visited February 11, 2021). The January 2020 VA examiner noted the FDA drug safety update submitted by the Veteran in August 2015 was not a peer-reviewed publication and failed to demonstrate a causal relationship between NSAIDs and atrial fibrillation, only a correlation. The Board finds the January 2020 VA examiner’s opinion that obesity is the proximate cause of the Veteran’s paroxysmal atrial fibrillation to be well-reasoned, supported by multiple recent medical publications, and based on a complete review of the Veteran’s claims file to be of great probative value. The January 2020 VA examiner also opined that the medical knowledge needed to determine the natural progression of atrial fibrillation in an individual does not exist, thus, there is no evidence to support a worsening of atrial fibrillation (aggravation) caused by medications taken to treat the Veteran’s left wrist tendonitis and migraine headaches. The Veteran has never asserted and has not identified any evidence of record suggestive of a relationship between the veteran’s obesity (or weight gain resulting in obesity) and any service-connected condition or medications prescribed for their treatment. At the Veteran’s most recent headaches examination, the VA examiner found the migraines had no effect on the Veteran’s ability to conduct the activities of daily living. See May 2011 VA examination report. The Veteran’s headaches were recently noted as being controlled by amitriptyline. See August 2020 VA treatment records. The Veteran has not sought treatment for his wrist condition, currently rated as 10 percent disabling, since March 2015. See VA treatment records. Accordingly, there is no reasonably raised theory of secondary service connection with obesity as an intermediate step. Garner v. Tran, No. 18-5865, 2021 U.S. App. Vet. Claims LEXIS 81, at 15 (Vet. App. Jan. 26, 2021). Therefore, the nexus element of secondary service connection is not established. Accordingly, for reasons and bases outlined above, the preponderance of the evidence is against the claim of entitlement to service connection for paroxysmal atrial fibrillation. As such, the benefit of the doubt doctrine is not for application, and service connection must be denied. See 38 U.S.C. § 5107(b). S. BUSH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G. Rouse, 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.