Citation Nr: 21024930 Decision Date: 04/26/21 Archive Date: 04/26/21 DOCKET NO. 16-05 746 DATE: April 26, 2021 ORDER Entitlement to service connection for heart disease is denied. Entitlement to service connection for hypertension is denied. FINDINGS OF FACT 1. The Veteran’s heart disease was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury, event, or disease. 2. The Veteran’s hypertension was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury, event, or disease. CONCLUSIONS OF LAW 1. The criteria for service connection for heart disease have not been satisfied. 38 U.S.C. §§ 1110, 1112, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 2. The criteria for service connection for hypertension have not been satisfied. 38 U.S.C. §§ 1110, 1112, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from September 1968 to September 1971. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a March 2014 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In September 2018 and October 2020, the Board remanded the matters to the Agency of Original Jurisdiction (AOJ) for additional development and they have since returned for further appellate review. Service Connection Generally, to establish service connection, a claimant must show: (1) a present disability; (2) an 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. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303; see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). A disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. VA has established certain rules and presumptions for chronic diseases, such as cardiovascular-renal disease and hypertension. See 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a); Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). With chronic diseases shown as such in service so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless attributable to intercurrent causes. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. § 3.303(b). In addition, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, chronic diseases are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). 1. Heart Disease The Veteran contends that his heart disease was caused by his active duty service and has existed since his military service. See February 2013 Statement in Support of Claim. Alternatively, he contends that his heart disease is secondary to service-connected Charcot-Marie-Tooth disease (CMT) because of its residual effects on his lower extremities. Id. The Veteran has a current heart disease disability. For example, at his July 2019, July 2020, and January 2021 VA examinations he was diagnosed with coronary artery disease. Thus, the remaining question is whether the current heart disease disability is related to service or service-connected CMT. Service treatment records show no complaints, diagnosis, or treatment related to a heart disease disability. During the July 1971 separation examination, evaluation of the heart was normal. In a September 1971 statement of medical condition, the Veteran reported that there had been no change in his medical condition since his separation examination. During a November 1973 reenlistment examination for Army National Guard service, evaluation of the heart was normal. A June 1980 private treatment record indicates a cardiovascular examination was unremarkable. A heart disease disability is not shown by medical evidence until approximately March 2006, many years after the Veteran’s separation from service. During a March 2006 cardiac catheterization, the Veteran was found to have nonobstructive atherosclerotic coronary artery disease. As heart disease disability is not shown to have been present during service or in the first year after separation of service, and continuity of symptomatology leading to a diagnosis of heart disease disability is not shown, in-service incurrence of heart disease disability cannot be presumed. See 38 C.F.R. §§ 3.307, 3.309(a). To the extent the Veteran asserts a continuity of symptomatology beginning during service, the Board finds these statements to lack credibility as they are in direct conflict with the separation examination where the Veteran’s heart was evaluated as normal. Furthermore, in a November 1973 reenlistment examination held approximately two years after the Veteran’s separation from active service, the Veteran’s heart was evaluated as normal. The Board finds the July 1971 separation examination and the November 1973 reenlistment examination to be more reliable than more recent assertions as it was done contemporaneous to service and for the purpose of identifying disability at that time. The Veteran presented for a VA examination in July 2019, at which time he was interviewed by the examiner who also reviewed the pertinent medical history and performed an examination. Regarding secondary service connection, the examiner opined that the claimed condition was less likely than not proximately due to or the result of the Veteran’s service-connected condition. The examiner further opined that the claimed condition was not at least as likely as not aggravated beyond its natural progression by service-connected condition. In support of this conclusion, the examiner explained that there was no supporting documentation found that supports a link between CMT and ischemic heart disease, and there was no documentation that supported the definition of ischemic heart disease. The definition provided by UpToDate noted that ischemic heart disease was inadequate supply of blood to the myocardium due to obstruction of the epicardial coronary arteries, mainly from atherosclerosis. The Veteran presented for a VA examination in July 2020, at which time he was interviewed by the examiner who also reviewed the pertinent medical history and performed an examination. 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. In support of this conclusion, the examiner opined that there is no determinable connection between heart conditions (ischemic heart disease and coronary artery disease) related to the Veteran’s military service. The examiner further noted that for a connection for military service and CMT disease there is no determined connection as CMT is a genetic disorder and the Veteran was noted to have trouble before he entered service and had an undiagnosed condition. Regarding secondary service connection, the examiner opined that the claimed condition was less likely than not proximately due to or the result of the Veteran’s service-connected condition. In support of this conclusion, the examiner opined that the two conditions are not medical related, and the claimed disorder is a separate entity entirely from the service-connected condition and unrelated to it. The examiner further opined that the medical literature does not support a medical relationship and thus, a nexus is not established. The examiner further opined that the Veteran’s heart disease was not at least as likely as not aggravated beyond its natural progression by service-connected condition. In support, the examiner opined that the Veteran has coronary artery disease that can be attributed to age and there is no evidence to support a connection between military service and his coronary artery disease. The Veteran presented for a VA examination in January 2021, at which time he was interviewed by the examiner who also reviewed the pertinent medical history and performed an examination. 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. In support of this conclusion, the examiner explained that the Veteran’s heart disease is less likely as not related to an inability to exercise over a period of years due to his service-connected CMT and bilateral ankle and foot disabilities. The examiner noted that exercise can be conducted in different forms. The examiner noted that while CMT may inhibit the ankles, arm exercises can also increase fitness levels. Therefore, the examiner opined that it is less likely than not that the claimed CMT caused decreased exercise. Regarding secondary service connection, the examiner opined that the claimed condition was less likely than not proximately due to or the result of the Veterans’ service-connected condition. The examiner further opined that the Veteran’s heart disease is not at least as likely as not aggravated beyond its natural progression by a service-connected condition. In support of this conclusion, the examiner explained that the though inactivity is a cause for increased risk for heart disease, there are multiple ways to maintain physical fitness. The examiner noted that fitness can be achieved through other forms of exercise such as swimming and arm exercises. The Board finds the VA medical opinions highly probative as they were made by a medical professional with consideration of the specific facts in this case and after examination of the Veteran. The opinions are also supported by other evidence of record. There are no medical opinion or competent and credible evidence in significant conflict with the VA medical opinions. Upon review of the evidence above, the Board finds that the evidence is against a finding of service connection for heart disease based on direct and secondary theory of entitlement. Initially, the Board notes that the record is absent of any medical opinion that supports either a direct or secondary service connection. The Board gives some probative weight to the July 2019 VA medical opinion which found not documentation to support secondary service connection. The Board gives great probative weight July 2020 VA medical opinion that found that there was no evidence to link military service to the Veteran’s coronary artery disease. This opinion is supported by the evidence of record, to include the Veteran’s service treatment record where the Veteran’s heart was evaluated as normal upon separation, and there was no medical evidence supporting a heart disease disability until March 2006. The Board gives great probative weight to the July 2020 VA medical opinion which found that the medical literature did not support a secondary service connection, as heart disease and CMT were unrelated conditions. Further, the Board gives great probative weight to the January 2021 VA medical opinion which found that heart disease was not caused by or aggravated beyond its natural progression by service-connected CMT as exercise can be conducted in various forms such as arm exercises. The Board notes that in making these determinations, the examiners had conducted examinations and reviewed the Veteran’s record. The Board has considered the Veteran’s statements, to include his assertions that his service-connected CMT prevented him from undertaking cardiovascular and physical training. See February 2015 Statement in Support of Claim, July 2016 RO Hearing Testimony at 42. When he lost the use of his lower extremities, the Veteran asserts that he was prevented from being able to maximize his cardiovascular exercise throughout his lifetime. Id. The Veteran further contends that the January 2021 VA medical opinion is inadequate as the examiner assumed that the Veteran could swim. See February 2021 Correspondence. As the Veteran is not shown to have medical education or experience, he is a lay person and is competent to report (1) symptoms that are observable to a layperson, e.g., chest pain; (2) symptoms at the time supporting a later diagnosis by a medical professional; or (3) a contemporaneous medical diagnosis. See Davidson v. Shinseki, 581 F.3d 1313 (2009). The Veteran is not competent to independently render a medical diagnosis or opine as to the specific etiology of a condition as these are medically complex issues. Thus, his lay assertions do not constitute evidence upon which service connection can be granted. Here, the examiner considered the Veteran’s impact of the service-connected CMT to the Veteran’s foot and ankle, but found that arm exercises can be a source of fitness exercise to alleviate the risk of heart disease. Further, while the Veteran indicated that he may no longer swim, the examiner noted that the Veteran can still perform arm exercises not limited to swimming. The Board ultimately assigns greater probative weight to the medical evidence of record, to include the opinion rendered by a trained medical professional based on appropriate diagnostic testing and reasonably drawn conclusions with supportive rationale. The examiner’s findings are supported by the record and the opinions took into consideration medical literature. For the above reasons, the preponderance of the evidence is against the claim and service connection is denied. 2. Hypertension The Veteran contends that his hypertension was caused by his active duty service. See February 2013 Statement in Support of Claim. Alternatively, he contends that his hypertension is secondary to service-connected CMT and residuals of the lower extremities that began during service. Id. The Veteran has a current hypertension disability. See July 2019, July 2020, and January 2021 VA Examination Reports. Thus, the remaining question is whether the current hypertension disability is related to service or service-connected disability CMT. Service treatment records show no complaints, diagnosis, or treatment related to hypertension. During the July 1971 separation examination, evaluation of the heart was normal. The Veteran’s blood pressure at separation was 118/82, which is not considered hypertensive by VA standards. See 38 C.F.R. § 4.104, Diagnostic Code 7101. In a September 1971 statement of medical condition, the Veteran reported that there had been no change in his medical condition since his separation examination. During a November 1973 reenlistment examination for Army National Guard service, evaluation of the heart was normal, and his blood pressure was 130/76. In a corresponding report of medical history, the Veteran specifically denied having had high or low blood pressure. If hypertension was present during the November 1973 report of medical history, the Board would expect the Veteran would have responded “yes” when asked if he had high blood pressure because a reasonable person would have interpreted the question to include symptoms for high blood pressure. A hypertension disability is not shown by medical evidence until approximately the 1990s, many years after the Veteran’s separation from service. In an April 1990 private treatment, the Veteran denied having a history of hypertension. Regarding onset of symptoms related to a hypertension disability, post-service the Veteran has reported elevated blood pressure in 1993. As hypertension is not shown to have been present during service or in the first year after separation of service, and continuity of symptomatology leading to a diagnosis of hypertension is not shown, in-service incurrence of hypertension cannot be presumed. See 38 C.F.R. §§ 3.307, 3.309(a). To the extent the Veteran asserts a continuity of symptomatology beginning during service, the Board finds these statements to lack credibility as they are in direct conflict separation examination findings where the Veteran’s blood pressure was normal, and notably, in 1973 when the Veteran specifically denied having had high blood pressure. The Board finds the examination findings at separation and the findings in 1973 to be more reliable than more recent assertions as they were done contemporaneous to service and for the purpose of identifying disability at that time. The Veteran presented for a VA examination in July 2019, at which time he was interviewed by the examiner who also reviewed the pertinent medical history and performed an examination. Regarding secondary service connection, the examiner opined that the claimed condition was less likely than not proximately due to or the result of the Veteran’s service-connected condition. Further, the examiner opined that the Veteran’s claimed condition was not at least as likely as not aggravated beyond its natural progression by the service-connected condition. In support of this conclusion, the examiner opined that there is a lack of medical literature evidence discovered to support a relationship between hypertension and CMT. The Veteran presented for a VA examination in July 2020, at which time he was interviewed by the examiner who also reviewed the pertinent medical history and performed an examination. 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. In support of this conclusion, the examiner explained that there was no evidence to link military service to the Veteran’s hypertension. Regarding secondary service connection, the examiner opined that the claimed condition was less likely than not proximately due to or the result of the Veteran’s service-connected condition. In support of this conclusion, the examiner explained that the examiner could not confirm a current chronic diagnosis with current available records, and thus, no nexus or plausible secondary relationship is established. The Veteran presented for a VA examination in January 2021, at which time he was interviewed by the examiner who also reviewed the pertinent medical history and performed an examination. 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. In support of this conclusion, the examiner explained that the Veteran’s hypertension is less likely as not related to an inability to exercise over a period of years due to his service-connected CMT and bilateral ankle and foot disabilities. The examiner noted that exercise can be conducted in different forms. The examiner noted that while CMT may inhibit the ankles, arm exercises can also increase fitness levels. Therefore, the examiner opined that it is less likely than not that the claimed CMT caused decreased exercise. Regarding secondary service connection, the examiner opined that the claimed condition was less likely than not proximately due to or the result of the Veterans’ service-connected condition. The examiner further opined that the Veteran’s hypertension is not at least as likely as not aggravated beyond its natural progression by service-connected condition. In support of this conclusion, the examiner explained that though inactivity is a cause for increased risk for heart disease, there are multiple ways to maintain physical fitness. The examiner noted that fitness can be achieved through other forms of exercise such as swimming and arm exercises. The Board finds the July 2020 VA medical opinion addressing secondary service connection to be less probative as it noted that a diagnosis could not be confirmed which is contradicted by a diagnosis found during the same examination. In contrast, the Board finds the remaining opinions highly probative as they were made by medical professionals with consideration of the specific facts in this case and after examination of the Veteran. The opinions are also supported by other evidence of record. There are no medical opinion or competent and credible evidence in significant conflict with the VA medical opinions. Upon review of the evidence above, the Board finds that the evidence is against a finding of service connection for hypertension based on direct and secondary theory of entitlement. The Board notes that the record is absent of any medical opinion that supports either a direct or secondary service connection. The Board gives some probative weight to the July 2019 VA medical opinion addressing secondary service connection, as it was given after the examiner reviewed medical literature and found no connection between CMT and hypertension. The Board gives great probative weight July 2020 VA medical opinion that found that there was no evidence to link military service to the Veteran’s hypertension. This opinion is supported by the evidence of record, to include the Veteran’s service treatment record where the Veteran’s hypertension was evaluated as normal upon separation, and where the Veteran specifically denied having had high blood pressure in 1973. The Veteran denied having a history of hypertension in an April 1990 private treatment. Further, the Board gives great probative weight to the January 2021 VA medical opinion which found that hypertension was not caused by or aggravated beyond its natural progression by service-connected CMT. The Board notes that in making these determinations, the examiners had conducted an examination and reviewed the record. The Board has considered the Veteran’s statements, to include his assertions that his service-connected CMT prevented him from undertaking physical training. See February 2015 Statement in Support of Claim, July 2016 RO Hearing Testimony at 42. When he lost the use of his lower extremities, the Veteran asserts that he was prevented from being able to maximize his cardiovascular exercise throughout his lifetime. Id. The Veteran further contends that the January 2021 VA medical opinion is inadequate as the examiner assumed that the Veteran could swim. See February 2021 Correspondence. As the Veteran is not shown to have medical education or experience, he is a lay person and is competent to report (1) symptoms that are observable to a layperson, e.g., chest pain; (2) symptoms at the time supporting a later diagnosis by a medical professional; or (3) a contemporaneous medical diagnosis. See Davidson, 581 F.3d at 1313. The Veteran is not competent to independently render a medical diagnosis or opine as to the specific etiology of a condition as these are medically complex issues. Thus, his lay assertions do not constitute evidence upon which service connection can be granted. Here, the examiner considered the Veteran’s impact of the service-connected CMT to the Veteran’s foot and ankle, but found that arm exercises can be a source of fitness exercise to alleviate the risk of hypertension. Further, while the examiner indicates that he may no longer swim, the examiner noted that the Veteran can still perform arm exercises not limited to swimming. The Board ultimately assigns greater probative weight to the medical evidence of record, to include the opinion rendered by a trained medical professional based on appropriate diagnostic testing and reasonably drawn conclusions with supportive rationale. The examiner’s findings are supported by the record and the opinions took into consideration medical literature.   For the above reasons, the preponderance of the evidence is against the claim and service connection is denied. M. C. WILSON Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Mathew 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.