Citation Nr: 21009354 Decision Date: 02/22/21 Archive Date: 02/22/21 DOCKET NO. 19-26 012A DATE: February 22, 2021 ORDER Entitlement to service connection for atrial fibrillation (claimed as heart condition) is denied. REMANDED Entitlement to an increased rating for residuals of status post stroke is remanded. FINDINGS OF FACT 1. The Veteran had service in Vietnam and was presumptively exposed to herbicides. 2. The Veteran’s atrial fibrillation was not incurred in service; is not related to service or caused or aggravated by a service-connected disability. CONCLUSIONS OF LAW The Veteran’s atrial fibrillation was not incurred in or aggravated by active military service; may not be presumed to have been incurred in service and is not related to a service-connected disability. 38 U.S.C. §§ 1101, 1110, 1112, 1113; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from June 1966 to October 1999. These matters come before the Board of Veterans’ Appeals (Board) on appeal from an August 2017 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). Entitlement to service connection for atrial fibrillation (claimed as heart condition) The Veteran contends that he is entitled to service connection for atrial fibrillation because he was exposed to herbicides. See February 2019 VA 21-526EZ. Alternatively, he claims that his atrial fibrillation is secondary to a service-connected disability because he developed it after he had a major stroke which was caused by his service-connected hypertension. See July 2017 VA examination report. For the reasons explained below, the Board finds that entitlement to service connection is not warranted. If a veteran was exposed to Agent Orange during active service, presumptive service connection is warranted for certain specified diseases. 38 C.F.R. §§ 3.307, 3.309. Initially, the Board notes that although there is evidence the Veteran served in Vietnam and was presumptively exposed to herbicides, atrial fibrillation is not listed as a disease associated with exposure to certain herbicide agents under 38 C.F.R. § 3.309 (e). Accordingly, entitlement to service connection on a presumptive basis is not warranted. Notwithstanding the foregoing, the appellant may still establish service connection on a direct basis. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). In order to obtain service connection under 38 U.S.C. § 1110 and 38 C.F.R. § 3.303 (a) a Veteran must satisfy a three element test: (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. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Secondary service connection is also available for those disabilities which are caused or aggravated by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (secondary service connection available for disabilities which are caused or aggravated by a service-connected disability). The Veteran’s service treatment records are silent for any heart complaints or diagnoses. The Veteran was first diagnosed with atrial fibrillation in March 2017. See Hope Medical Clinic records. The Veteran was afforded a VA heart conditions examination in July 2017 where the examiner opined that it was less likely than not that the Veteran’s atrial fibrillation was related to service. He reasoned that there was no pathophysiological evidence to link the atrial fibrillation to service. In a July 2019 medical opinion, the clinician opined that it was less likely than not that the Veteran’s atrial fibrillation was secondary to his service-connected hypertension. The clinician reasoned that, “[t]he two conditions are not medically related. The claimed atrial fibrillation [AFib] disorder is a separate entity entirely from the service-connected condition and unrelated to it. Afib increases markedly with older age. Longstanding, uncontrolled high blood pressure can increase the risk for Afib.” In January 2020, the Board requested clarification of the opinion. In a March 2020 medical opinion, the clinician opined that it was less likely than not that the Veteran’s atrial fibrillation was caused or aggravated by a service-connected disability. The clinician reasoned that atrial fibrillation is a common finding in the Veteran’s age category. The clinician noted that the Veteran’s hypertension had been controlled with Lisinoprol and Hydrochlorothiazide. “Additionally, hypertensive heart disease is again a separate and independent vascular condition which is unrelated to atrial fibrillation. Veteran continues to present with atrial fibrillation on EKG despite stable and controlled blood pressure.” Based on the foregoing, the Board finds the March 2020 VA examination report to be the most probative evidence of record. A medical opinion is most probative if it is factually accurate, fully articulated, and based on sound reasoning. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The March 2020 examination report clarified the July 2019 report and indicated that the Veteran’s atrial fibrillation was more likely than not related to the Veteran’s advanced age and not related to service or his service-connected disabilities. The clinician also explained why the Veteran’s service-connected hypertension did not cause or aggravate the Veteran’s atrial fibrillation. The clinician addressed potentially favorable evidence and concluded that the Veteran’s atrial fibrillation was not service connected – either directly or secondarily. Instead, the clinician associated the Veteran’s atrial fibrillation to his advanced age. The fact that he developed the atrial fibrillation after he had a stroke does not mean that there is a correlation between the two. The March 2020 clinician dispelled any such conclusion. It is clear that the Veteran believes that a nexus exists. Such a lay belief sometimes is sufficient. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). It indeed is error to suggest that lay evidence can never be enough to establish that there is a nexus between a claimed condition and service. See Colantonio v. Shinseki, 606 F.3d 1378 (Fed. Cir. 2010); Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010). However, the etiology of atrial fibrillation is a complex medical issue, which the Veteran is not qualified to offer an opinion. Thus, while the Board has considered the Veteran’s statements, it finds the VA examination opinion to outweigh them. There is no other contrary medical opinion to support the Veteran’s contentions. In conclusion, the preponderance of the evidence is against the Veteran’s claim; therefore, the benefit of the doubt provision does not apply. REASONS FOR REMAND Entitlement to an increased rating for residuals of status post stroke is remanded. The Veteran has contended that since his stroke he has suffered from short term memory loss and difficulty recalling things with which he was very familiar. He reports that his speech therapist told him he may never regain cognitive abilities. See September 2017 Notice of Disagreement. To date, the Veteran has only been compensated for his right upper and lower extremity loss of function as a residual of his service-connected stroke. The Veteran contends that he is additionally entitled to compensation for his neurological residuals due to his service-connected stroke. At a July 2019 VA mental disorders examination, the examiner opined that the Veteran did not suffer from any cognitive dysfunction as a result of his stroke. At a July 2019 central nervous system examination, the examiner noted that the Veteran reported suffering from mild short-term memory loss. No etiological opinion was provided regarding the short-term memory loss. At a March 2020 VA peripheral nerve examination, the examiner noted the Veteran’s subjective reports of symptoms of memory loss; restricted speech and impaired thought. At a March 2020 central nervous system and neuromuscular diseases examination, the examiner noted that there was no objective evidence of anomia or memory loss on examination. The Board finds that a remand is necessary to afford the Veteran a VA examination by a neurologist who can opine whether the Veteran suffers from cognitive impairment including memory loss and anomia, that are a result of his service-connected post status stroke. The Board notes that the previous central nervous system examinations (authored by a nurse practitioner) fall short of addressing the Veteran’s reported symptoms of memory loss; restricted speech and impaired thought. Therefore, the Board finds a remand is necessary to afford the Veteran an appropriate examination by a doctor who specializes in treating post-stroke neurological symptoms. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination by a neurologist (or doctor experienced in post-stroke rehabilitation) to determine the current severity of his residuals of post status stroke. The examiner should address whether the Veteran suffers from symptoms of cognitive deficits; short-term memory loss; restricted speech and episodes of anomia, which are related to his 2015 stroke. See VA June 2015 treatment records from B.S., speech therapist; September 2017 Notice of Disagreement; March 2020 VA peripheral nerve examination report. The previous examiners did not address the etiology of the Veteran’s complaints of short-term memory loss. *The Board also requests that the examiner provide diagnoses for any of the neurological symptoms the Veteran experiences as a result of his stroke.* 2. Thereafter, readjudicate the issue on appeal as noted above. If the determination remains unfavorable to the Veteran, he should be furnished a supplemental statement of the case (SSOC) which addresses all evidence associated with the claims file since the last statement of the case. The Veteran should be afforded the applicable time period to respond. Michael A. Pappas Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Baskerville, LaRita 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.