Citation Nr: 21023598 Decision Date: 04/21/21 Archive Date: 04/21/21 DOCKET NO. 18-31 293 DATE: April 21, 2021 ORDER Entitlement to service connection for coronary artery disease, status post myocardial infraction and mitral valve replacement (also claimed as heart condition) as secondary to medications taken for the service-connected seizure disorder, is denied. FINDING OF FACT The Veteran’s coronary artery disease, status post myocardial infraction and mitral valve replacement (also claimed as heart condition), (CAD), is not etiologically related to medications taken for the service-connected seizure disorder. CONCLUSION OF LAW The criteria for service connection for coronary artery disease, status post myocardial infraction and mitral valve replacement (also claimed as heart condition) have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2019). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran honorably served on active duty from October 1968 to September 1972. This matter comes before the Board of Veterans’ Appeals (Board) on appeal of a January 2017 rating decision issued by the Department of Veterans Affairs (VA). The Veteran submitted a timely notice of disagreement (NOD) in March 2017. The VA Regional Office (RO) issued a statement of the case (SOC) in May 2018, and the Veteran perfected his appeal in May 2018 with the submission of a timely VA Form 9. In January 2020, the Board remanded the Veteran’s claim to the RO for further development. The RO issued a supplemental statement of the case (SSOC) in August 2020. This matter is now properly before the Board. In a letter dated in March 2021, the Veteran was notified that the VLJ who conducted the November 2019 Board hearing was no longer employed by the Board and that the Veteran had the right to another Board hearing. The Veteran responded that he does not desire another Board hearing. Service Connection 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, 1131; 38 C.F.R. § 3.303 (a). Establishing service connection generally requires (1) evidence of a current disability; (2) 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 present disability. Shedden v. Principi, 381 F. 3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff’d per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table); 38 C.F.R. § 3.303. Service connection may also be granted for any disease diagnosed after the military discharge, when all the evidence, including that pertinent to the period of military service, establishes that the disease was incurred during the active military service. 38 U.S.C. § 1113(b); 38 C.F.R. § 3.303(d). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.310. In order to prevail on the theory of secondary service connection, there must be evidence of a current disability; evidence of a service-connected disability; and evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for the evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. 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 Veteran 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 Veteran. 1. Entitlement to service connection for CAD. The Veteran contends that he is entitled to service connection for CAD as secondary to his previously service-connected seizure disorder. In December 2016, the Veteran was afforded a VA examination. The examiner opined that it is less likely than not that a seizure disorder has any effect on causing CAD or valvular heart disease based on physiology of a seizure disorder and heart disease. In April 2019, the Veteran was afforded another VA exam, the examiner noted that the Veteran’s CAD was less likely than not proximately due to or the result of a service-connected condition. The examiner indicated that there is no medical evidence of levetiracetam causing or aggravating any cardiovascular condition. The examiner also provided additional rationale that according to Up To Date there is no medical evidence of levetiracetam causing or aggravating any cardiovascular condition. In January 2020, the Veteran had a VA exam to provide an opinion as to the connection between the Veteran’s seizure medications and the Veteran’s CAD. The examiner noted that a review of the current drug literature shows no evidence that any of the Veteran’s prescribed seizure medications have any adverse effect (causal or aggravation) on the cardiovascular system. The examiner opined that the Veteran’s heart disease is due to atherosclerosis. Atherosclerosis is a pathologic process that causes disease of the coronary, cerebral, and peripheral arteries. Atherosclerosis begins in childhood with the development of fatty streaks. The examiner went on to note that Phenytoin (Dilantin) is an established drug in the treatment of acute repetitive seizures and status epilepticus. One of its main advantages over benzodiazepines is the less sedative effect. The examiner noted that the possibility of cardiovascular adverse effects come with intravenous use of phenytoin, and a rapid infusion rate appeared to cause mortality. Here, there is no indication that the Veteran is taking the medication intravenously. The examiner also noted that the Veteran’s coronary artery disease, status post myocardial infraction and mitral valve replacement (also claimed as heart condition) was not aggravated beyond its natural progression by medication for his service-connected disorder. In a medical note dated December 2019, the Veteran’s physician describes the impact that the Veteran’s treatment for seizures has impacted his general cognitive slowing and memory loss. The physician did not make any mention of the Veteran’s seizure medication impacting his CAD. The physician noted that the Veteran did have CAD and that it did cause overall medical problems, but there was no link made between the Veteran’s CAD and his seizure disorder. In a medical note from Neurology dated June 2020, the Veteran’s neurologist indicated that the Veteran had falls and memory problems, but that was being followed up with the Veteran’s primary care doctor. The neurologist noted that he believed it was safe to keep prescribing him donepezil. In a November 2019 hearing before the Board, the Veteran stated that he would submit a medical opinion from his primary care physician showing the nexus between the Veteran’s CAD and the seizure medications. The Board has thoroughly reviewed the Veteran’s claims file and that evidence has not been submitted. The Veteran requested additional time to submit medical records and additional evidence for the Board to review on December 6, 2020. The Veteran’s motion was granted, but any such evidence has not been submitted. The time to submit evidence has now been closed. Additional requests for extension of time to submit evidence have not been received, and therefore the record of evidence is closed. The Board finds that the Veteran does have a current disability, CAD. The Board also finds that the Veteran has a service-connected disability, seizure disorder. However, there is no evidence that supports the Veteran’s contention that there is a connection between the service-connected seizure disorder and CAD. Therefore, the elements for secondary service connection have not been met. See Wallin v. West, 11 Vet. App. 509, 512 (1998). The Board has sympathetically reviewed the Veteran’s claim for service connection of CAD and the evidence of record. After careful review, there is no evidence of record that indicates that the Veteran’s CAD is caused or aggravated by his seizure disorder or the medications he takes for his seizure disorder. The Board believes the Veteran is competent to report the symptoms of his disability, however he is not competent to determine the etiology of the cause of his disability. The Board finds the January 2020 VA examiner to be competent, credible and the opinion to be highly probative. The examiner addressed the issues of causation and aggravation as requested in the Board’s 2020 remand instructions. The Veteran bears the evidentiary burden to establish all elements of a service connection claim. Fagan v. Shinseki, 573 F. 3d 1282, 1287-88 (2009). Given the absence of evidence showing an etiological connection between the Veteran’s service-connected seizure disorder and the Veteran’s CAD, the Board finds that the Veteran has not substantiated his claim for service connection for CAD. VA treatment records added to the record subsequent to the most recent SSOC merely reflect that the Veteran continues to be treated for his heart condition, they are not relevant to the etiology of the heart condition. Therefore, the Board the Board finds that the preponderance of the evidence is against entitlement service connection for the Veteran’s CAD. Hart v. Mansfield, 21 Vet. App. 505 (2007). N. RIPPEL Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Hellina Y. Hailu, 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.