Citation Nr: 21013789 Decision Date: 03/10/21 Archive Date: 03/10/21 DOCKET NO. 14-31 218A DATE: March 10, 2021 ISSUE Entitlement to service connection for a heart disability. ORDER Entitlement to service connection for a heart disability is denied. FINDINGS OF FACT The preponderance of competent and credible evidence weighs against a finding that a heart disability demonstrated in service or for many years thereafter; or that there is a nexus between this claimed disability and service. CONCLUSION OF LAW The criteria for service connection for heart disability have not been met. 38 U.S.C. §§ 1101, 1131, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). REASONS FOR FINDINGS AND CONCLUSION The Veteran served on active duty from June 1980 to June 1984. This case is before the Board of Veterans’ Appeals (Board) on appeal from an April 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky. In September 2015 the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. A transcript of her testimony is associated with the record. When this case was previously before the Board in February 2020, it was remanded for additional evidentiary development. It has since been returned to the Board for further appellate action. The Board finds that there has been substantial compliance with the remand directives, and the case has been properly returned to the Board for further appellate action. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107 (2012); 38 C.F.R. §§3.102, 3.156(a), 3.159, 3.326(a) (2017). The Veteran in this case has not referred to any deficiencies in either the duties to notify or assist; therefore, the Board may proceed to the merits of the claim. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed.Cir. 2015, cert denied, U.S.C. Oct.3, 2016) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board....to search the record and address procedural arguments when the [appellant] fails to raise them before the Board”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to an appellant’s failure to raise a duty to assist argument before the Board). The Board has reviewed all of the evidence in the Veteran’s claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on her behalf be discussed in detail. Rather, the Board’s analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-130 (2000). Service Connection Claims Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. In this case, the Board notes that service connection on a presumptive basis is not warranted. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). 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. In order to establish service connection for the claimed disorder, there must be (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) evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). Analysis In this case, the Veteran has diagnoses of atherosclerotic cardiovascular disease and coronary artery disease (CAD) (also known as ischemic heart disease or IHD); accordingly, Hickson element (1) is therefore satisfied. With regard to Hickson element (2), evidence of an in-service incurrence of a disease or injury, service treatment records show that on March 5, 1982, she was seen for possible heat exhaustion with no sweating while running; she reported that it felt like her heart was beating in her head, a throbbing sensation, and dizziness. A report on March 15, 1982, showed a notation of pre-syncopal sensation for the incident on March 5th. On March 18, 1982, the Veteran complained of dizziness and throbbing in her head during a physical fitness test; there was no shortness of breath, palpitations, or chest pains. On May 13, 1982, a history of heart murmur was noted. On May 18, 1982, a history of cardiac murmur, but without evidence of cardiac disease was noted, and the Veteran was cleared for oral surgery and/or any other dental procedures under consideration. Examination at that time revealed no cardiac or blood pressure problems with the impression of vasovagal pre-syncopal episode. Examination revealed that the first heart sound (S1) was normal; the second heart sound (S2) had no gallop, murmur, jugular venous distention, or carotid bruit. The assessment was rule out diabetes (DM); rule out idiopathic hypertrophic subaortic stenosis (I HSS); probable vasovagal. Accordingly, Hickson element (2) is at least arguably satisfied for the issue on appeal. The Veteran was afforded a VA examination in March 2019 in which the examiner stated that the she noted “palpitations” since her time on active duty and continued to note intermittent palpitations, unrelated to activity. The examiner stated that service treatment records were silent for the evaluation of heart palpitations. The examiner reported that on March 13, 1982, the Veteran was evaluated for history of murmur; physical examination did not reveal a murmur at that time, and antibiotic prophylaxis was not recommended. The examiner stated that the cause of heart palpitations were often not found and could include noncardiac causes such as anxiety, depression, stimulants, fever, hormone changes, and thyroid disorders; cardiac causes included arrhythmias. The examiner stated that the Veteran’s medical records were silent for a cardiac arrhythmia resulting in ongoing palpitations. The examiner stated that there was no medical evidence of a disabling heart condition while on active duty to the present; therefore, the Veteran’s heart palpitation were less likely than not due to the diagnosed CAD and trace mitral valve and trace tricuspid valve insufficiencies, which were diagnosed more than 25 years after active duty service. The examiner stated that there was no evidence of valvular heart disease or CAD during active duty service. The Board noted in pertinent part in the February 2020 remand that in-service treatment records noted a history of heart murmur and complaints to include feeling like her heart was beating in her head, a throbbing sensation, and dizziness should have been addressed. As such, the Board remanded this case to afford the Veteran a VA examination performed by a cardiologist. Subsequently, in April 2020 a negative etiological medical opinion was provided by a physician’s assistant. In May 2020 a negative etiological medical opinion was provided by a nurse practitioner. As these opinions were not provided by cardiologists, the Board will not discuss them further. In October 2020 the Veteran was afforded a VA-contracted examination by a physician specializing in cardiovascular disease. The examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner stated that IHD diagnosed in 2016 was unrelated to her chronic history of palpitations. The examiner stated that the Veteran did not have signs or symptoms of IHD during her service. The examiner stated that during service, a vasovagal episode was acute only; the Veteran received treatment and the symptoms resolved with no evidence of chronicity. The examiner stated that there was no evidence of chronicity of care and symptoms were subjective with palpitations and tachycardia not clearly associated with any pathologic cardiac arrhythmia. The examiner stated that the Veteran’s palpitations were possibly non-cardiac in etiology, given the numerous negative tests that have occurred. The examiner stated that it was possible that the Veteran felt occasional premature beats, but these were benign in nature and did not warrant consideration as an in-service illness. The examiner concluded that a nexus was not established. In this case, as to the issue of the etiology of the Veteran’s claimed heart disability, the Board finds that the VA examiner made it clear that it was his opinion that the heart disability was not related to nor had onset in service. To this point, the Board notes that medical reports must be read as a whole, and the Board is permitted to draw inferences based on the overall report so long as the inference does not result in a medical determination. Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012). No other competent opinion providing a positive nexus between the heart disability and service has been presented. Accordingly, the Board concludes that the VA opinions carry significant weight. The Board acknowledges that the Veteran is competent to testify as to her beliefs that her heart disabilities are related to service. However, there is nothing in the record to suggest that the Veteran has the appropriate training, experience, or expertise to render a medical opinion regarding etiology. See 38 C.F.R. § 3.159 (a)(1) (2017) (setting forth that competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions). While the Veteran is competent to report what she has experienced, she is not competent to ascertain the etiology of any current condition, as the causative factors for such are not readily subject to lay observation. See Charles v. Principi, 16 Vet. App. 370, 374-75 (2002); Layno v. Brown, 6 Vet. App. 465 (1994). The Board finds the VA examiner opinions are competent and probative as they were rendered after an evaluation of the Veteran, review of the Veteran’s history, and consideration of medical principles by licensed medical professionals. Therefore, a nexus between the Veteran’s heart disability and service cannot be established, and the criteria of Hickson element (3) are not met. In reaching this determination, the Board acknowledges that VA is statutorily required to resolve the benefit-of-the-doubt in favor of the Veteran when there is an approximate balance of positive and negative evidence regarding the merits of an outstanding issue. That doctrine, however, is not applicable in this case because the preponderance of the evidence is against the Veteran’s claim. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); 38 U.S.C. § 5107(b) (West 2014). MICHAEL A. PAPPAS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R.M.K., 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.