Citation Nr: 21009172 Decision Date: 02/19/21 Archive Date: 02/19/21 DOCKET NO. 16-02 076 DATE: February 19, 2021 ORDER Service connection for vasovagal syndrome (vasodepressor syncope) (including as secondary to mitral valve prolapse) is denied. Service connection for upper airway resistance syndrome (claimed as sleep apnea) is denied. FINDINGS OF FACT 1. The results of a July 2020 VA examination indicate that it is less likely than not that the Veteran’s vasodepressor syncope was causally related to service because the Veteran’s service treatment records and post-service April 1998 examination indicate that the Veteran did not report any syncopal episodes until August 2005 and was not diagnosed with vasodepressor syncope until a March 2011 examination. The results of a July 2020 VA examination also indicate that it is less likely than not that the Veteran’s vasodepressor syncope was causally related to his service-connected mitral valve prolapse because vasodepressor syncope involves an abnormality of normal regulation of blood pressure and heart rate response in relation to positional changes which is a separate condition from mitral valve prolapse. 2. The results of a July 2020 VA examination indicate that it is less likely than not that the Veteran’s sleep apnea was causally related to service because the Veteran’s service treatment records and post-service sleep studies examinations indicate that the Veteran did not display abnormal findings until well after service in June 2018. CONCLUSIONS OF LAW 1. The criteria for service connection for vasodepressor syncope (including as secondary to mitral valve prolapse) have not been met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309. 2. The criteria for service connection for sleep apnea have not been met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.303, 3.307. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a Veteran who served on active duty from November 1990 to May 1994. These matters are before the Board of Veterans’ Appeals (Board) on appeal from a February 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In May 2017, a Travel Board hearing was held before the undersigned; a transcript is in the record. These matters were before the Board in September 2018 and were remanded for further development. Service Connection Legal Criteria Generally, direct service connection may be established for a disability resulting from a disease, injury, or event, incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. To establish service connection, the following must be shown: (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. See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). “Secondary” service connection may be granted for a disability that is proximately due to, or aggravated by, a service-connected condition. 38 C.F.R. § 3.310. 1. Service connection for vasodepressor syncope (including as secondary to mitral valve prolapse) is denied. Factual Background The Veteran reported at an August 2005 VA treatment that he had a history of passing out for ten years, since 1995. The Veteran was seen for tilt-table testing in March 2011, which was positive for vasodepressor syncope. At a September 2012 VA examination, the conducting physician indicated that the Veteran has vasopressor syncope but it was unclear whether it was mimicking narcolepsy. The Veteran reported at an October 2017 VA treatment that he had a history of vasodepressor syncope dating back to service in 1992. Although the Veteran reported frequent episodes of narcolepsy and sleepiness, the Veteran was not treated for vasodepressor syncope during service. See service treatment records. The Veteran was afforded a July 2020 VA examination during which the conducting physician opined that it was less likely than not that the Veteran’s vasodepressor syncope was causally related to service. As a rationale, the physician explained that the Veteran’s service treatment records show no evaluation for or diagnosing of syncope during service. The physician noted that the service treatment records indicate that the Veteran reported excessive sleepiness which was resulted in a diagnosis of narcolepsy, a different and separate condition from syncope. The physician further noted that the Veteran was provided a neurological examination after exiting from service during which he was not diagnosed with syncope. See April 1998 examination. The physician finally noted that the Veteran was not diagnosed with vasodepressor syncope until March 2011. The RO requested an addendum opinion from the July 2020 VA examiner to determine whether the Veteran’s vasodepressor syncope was causally related to his service-connected mitral valve prolapse. In September 2020, the physician opined that the Veteran’s vasodepressor syncope was a separate and distinct condition from his mitral valve prolapse. The physician explained that the vasodepressor syncope involves an abnormality of normal regulation of blood pressure and heart rate response in relation to positional changes which is a separate condition from mitral valve prolapse. The physician also explained that the Veteran’s echocardiographic evaluations from December 2012 and March 2019 indicate that the Veteran’s mitral valve was reported to be normal and thus there is no further evidence of mitral valve prolapse condition. Analysis The Board finds that the preponderance of the evidence is against a finding that the Veteran’s vasodepressor syncope is causally related to his service. The Board affords probative value to the July 2020 VA examiner’s opinion because they indicated that they reviewed the claims file and supported their opinion with a rationale. Indeed, the Veteran’s service treatment records and post-service April 1998 examination indicate that the Veteran did not report any syncopal episodes. The Veteran did not report syncopal episodes until an August 2005 and was not diagnosed with vasodepressor syncope until a March 2011 examination. The Board acknowledges that the Veteran provided statements that he has experienced syncopal episodes since 1992. While the Veteran is competent to report observable symptoms, he has not indicated that he has the training or credentials to provide a diagnosis of vasodepressor syncope or whether it was causally related to his service. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (2007). The Board also affords probative value to the September 2020 VA examiner’s opinion that it is less likely than not that the Veteran’s vasodepressor syncope is causally related to his service-connected mitral valve prolapse. The examiner supported his opinion with a rationale by explaining vasodepressor syncope involves an abnormality of normal regulation of blood pressure and heart rate response in relation to positional changes which is a separate condition from mitral valve prolapse. The physician also explained that the Veteran’s echocardiographic evaluations from December 2012 and March 2019 indicate that the Veteran’s mitral valve was reported to be normal and thus there is no further evidence of mitral valve prolapse condition. Accordingly, service connection for vasodepressor syncope is denied. 2. Service connection for sleep apnea is denied. Factual Background The Veteran reported frequent episodes of narcolepsy and sleepiness during service, but his service records do not mention a diagnosis of sleep apnea. See service treatment records. The Veteran’s spouse submitted a May 2007 statement indicating that the Veteran has been experiencing the effects of sleep apnea since 1989. The Veteran’s spouse reported that she has had to repeatedly wake him up from choking every night for the past 7 years, since 2000. The Veteran was afforded an April 2000 sleep study during which the conducting examiner indicated that the results did not confirm sleep apnea. The examiner noted that cannabis was present on the urine screening despite denial of use of illicit drugs or alcohol. The examiner explained that marijuana can contribute to excessive daytime sleepiness. The Veteran was afforded a December 2005 sleep study during which the conducting examiner noted that the Veteran had persistent snoring and his documented limb movement were associated with respiratory event related arousals (RERAs). The Veteran later underwent a March 2011 sleep study during which he displayed an apnea hypopnea index (AHI) of 4.5. The Veteran testified at the Board hearing that during service he had difficulty sleeping at night and would wake up gasping for air. At a June 2018 VA sleep medicine consultation, the conducting physician indicated that the Veteran’s insomnia may possibly be due to, at least in part, to untreated sleep apnea. At an August 2018 VA treatment, the conducting physician indicated that the Veteran had mild sleep apnea characterized by AHI of 12 and supine AHI of 49. At a July 2020 VA examination, the conducting physician opined that it was less likely than not that the Veteran’s sleep apnea was causally related to his service. As a rationale, the physician indicated that the Veteran’s service treatment records were absent for a diagnosis of sleep apnea. The physician explained that the Veteran was evaluated for sleep apnea multiple times and findings were normal until the June 2018 sleep study showed AHI consistent with sleep apnea. The physician also opined that the Veteran’s sleep apnea was a totally distinct and separate condition from his diagnosed narcolepsy. The physician explained that sleep apnea is caused by transient obstruction of the oropharynx during sleep causing reduction of oxygen levels and increase in carbon dioxide levels triggering the patient frequently wake up at night to restore respiratory balance. Analysis The Board finds that the preponderance of the evidence is against a finding that the Veteran’s sleep apnea is causally related to his service. The Board affords probative value to the July 2020 VA examiner’s opinion because they indicated that they reviewed the claims file and supported their opinion with a rationale. Indeed, the Veteran’s service treatment records and post-service sleep studies examination indicate that the Veteran did not display abnormal findings until June 2018. The Board also affords probative value to the examiner’s opinion that it is less likely than not that the Veteran’s sleep apnea is related to his narcolepsy. The examiner supported his opinion with a rationale by explaining sleep apnea is a totally distinct and separate condition from his diagnosed narcolepsy and discussed how sleep apnea is caused. The Board acknowledges that the Veteran and his spouse have provided statements that the Veteran has experienced sleep apnea since 1989. While the Veteran and his spouse are competent to report observable symptoms, they have not indicated that they have the training or credentials to provide a diagnosis of sleep apnea or whether it was causally related to his service. See Jandreau supra. Accordingly, service connection for sleep apnea is denied. VICTORIA MOSHIASHWILI Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Alexander Bahus 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.