Citation Nr: 21032724 Decision Date: 05/27/21 Archive Date: 05/27/21 DOCKET NO. 19-34 530 DATE: May 27, 2021 ORDER Service connection for a heart disorder to include, acute ischemic stroke, cerebrovascular accident, right bundle branch block, and sinus bradycardia is denied. FINDING OF FACT The Veteran's heart disorder was not incurred in caused by his exposure to herbicide agents during service in the Republic of Vietnam. CONCLUSION OF LAW The criteria to establish service connection for a heart disorder have not been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.307(a)(3), (a)(6)(iii), 3.309(a), (e). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the U.S. Air Force from September 1964 to March 1976 and from October 1980 to 1984, to include service in the Republic of Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2018 rating decision of the Salt Lake City, Utah Regional Office (RO) In August 2020, the Board remanded the appeal to the RO for additional action. There was substantial compliance with the Board's remand directives. Stegall v. West, 11 Vet. App. 268 (1998). Service Connection - Heart disorder Service connection may be granted for a current disability arising from a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131. 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. 38 C.F.R. § 3.303(d). Service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of an in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). A veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. The last date on which such a veteran shall be presumed to have been exposed to an herbicide agent shall be the last date on which he or she served in the Republic of Vietnam during the period beginning on January 9, 1962 and ending on May 7, 1975. "Service in the Republic of Vietnam" includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 C.F.R. § 3.307 (a)(6)(iii). If a veteran was exposed to an herbicide agent during active military, naval, or air service, then ischemic heart disease (including but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina) shall be service-connected if the requirements of § 3.307(a)(6) are met even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of § 3.307(d) are also satisfied. 38 C.F.R. § 3.309(e). Note (2) states that for purposes of § 3.309(e), the term ischemic heart disease does not include hypertension or peripheral manifestations of arteriosclerosis such as peripheral vascular disease or stroke, or any other condition that does not qualify within the generally accepted medical definition of ischemic heart disease. Id. Cerebrovascular accident, as brain thrombosis, is a "chronic disease" listed under 38 C.F.R. § 3.309(a). Therefore, the provisions of 38 C.F.R. § 3.303(b) are for application. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Where the evidence shows a "chronic disease" in service or "continuity of symptoms" after service, the disease shall be presumed to have been incurred in service. For the showing of "chronic" disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such during active service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected unless they are clearly attributable to intercurrent causes. Generally, if a condition noted during active service is not shown to be chronic, then, a "continuity of symptoms" after service is required to establish service connection. 38 C.F.R. § 3.303(b). Additionally, as a chronic disease, cerebrovascular accident will be considered to have been incurred in or aggravated by service if the disease becomes manifest to a compensable degree within one year from the date of service separation. 38 C.F.R. § 3.307(a)(3). The Veteran asserts that his in-service chest pain was a manifestation of his current heart disorder. The claim will be denied under theories of presumptive service connection under § 3.309(a), (e), and direct service connection under § 3.303(d). The Veteran's military personnel records (MPRs) reflect that the Veteran served in the Republic of Vietnam from December 1968 to December 1969, June 1970 to August 1970, and February 1972 to January 1975. The Veteran is therefore presumed to have been exposed to herbicide agents, to include Agent Orange. However, the Veteran's diagnosed heart disorders acute ischemic stroke, cerebrovascular accident, right bundle branch block, and sinus bradycardia are not listed as diseases associated with exposure to certain herbicide agents under § 3.309(e). In particular, note (2) under the regulation states that ischemic heart disease does not include stroke, or any other condition that does not qualify within the generally accepted medical definition of ischemic heart disease. The Veteran is therefore not entitled to presumptive service connection under 38 C.F.R. § 3.309(e). A March 1971 service chest radiograph revealed pneumonia. A March 1972 service treatment record (STR) reflects the Veteran's report of experiencing shortness of breath and chest pain. In the Veteran's May 1972 service medical examination report, no heart abnormalities were noted. In a September 1974 STR, the Veteran reported experiencing occasional anterior chest pressure sensation associated with shortness of breath. The Veteran reported drinking six to eight cups of coffee per day and smoking a pack of cigarettes daily. The service medical examiner's impression was no evidence of heart disease and intermittent premature heart beats due to heavy coffee consumption. In the Veteran's September 1974 service medical examination report, no heart abnormalities were noted. In his September 1974 service medical history report, the Veteran answered "no" to the question of whether he then had, or once had shortness of breath, palpitation or a pounding heart, or heart trouble and "yes" to the question of whether he then had, or once had chest pain or pressure. The service medical examiner indicated that the Veteran's chest pain referred to pain experienced after strenuous work or exercise. In service medical examination reports dated May 1976, June 1980, and May 1983, no heart abnormalities were noted. A June 1984 STR reflects the Veteran's report of experiencing chest pain; however, no diagnosis was provided. In the Veteran's June 1984 service medical examination report, no heart abnormalities were noted. In his June 1984 service medical history report, the Veteran answered "no" to the question of whether he then had, or once had heart trouble and "yes" to the question of whether he then had, or once had shortness of breath, chest pain or pressure, and palpitation or pounding heart. The service medical examiner indicated that the Veteran's shortness of breath referred to smoking and the Veteran experienced episodes of irregular heartbeat since 1973 with no diagnosis and an unknown etiology. In the Veteran's August 1984 pre-separation medical examination report, no heart abnormalities were noted. In his August 1984 pre-separation medical history report, the Veteran answered "no" to the question of whether he then had, or once had shortness of breath, chest pain or pressure, or palpitation or a pounding heart. In an October 1984 STR, a heart examination revealed normal rate and rhythm. The service medical examiner not mid-systolic click without murmur, without S3, or S4 gallops. A January 1985 STR reflects the Veteran's report of experiencing right-sided chest pain and shortness of breath for two days. He was diagnosed with pneumonia. A March 1986 service chest radiograph revealed that the Veteran's heart size was normal. The STRs are highly probative evidence because they were generated with the specific view of recording the events they describe. In this respect, they are akin to official records, which generally enjoy a high degree of probative value in the law. Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (observing that although formal rules of evidence do not apply before the Board, recourse to the Federal Rules of Evidence may be appropriate if it assists in the articulation of the reasons for the Board's decision). A May 2018 non-VA treatment record reflects the Veteran's report of experiencing sudden onset left facial droop, left arm weakness, and left leg weakness. A brain radiograph revealed mild diffuse cerebral atrophy and a chest radiograph revealed mild cardiomegaly with no evidence of congestive heart failure or pneumonia. The Veteran was diagnosed with acute ischemic left middle cerebral artery stroke. A subsequent May 2018 non-VA treatment record reflects the Veteran's diagnosis of acute ischemic stroke. A July 2018 VA treatment record reflects the Veteran's diagnosis of cerebrovascular accident due to an embolism of the right middle cerebral artery. VA treatment records do not reflect any complaints, contemporaneous reports, or treatment pertaining to the Veteran's heart disorder. During the December 2020 VA examination, a chest radiograph revealed no evidence of acute cardiopulmonary disease and the Veteran was diagnosed with right bundle branch and sinus bradycardia. The examiner indicated that the Veteran's heart disorders did not qualify within the generally accepted medical definition of ischemic heart disease. The examiner opined that the Veteran's heart disorder was not caused by exposure to herbicide agents because the Veteran's in-service reports of chest pain were attributed to excessive coffee consumption, the May 2018 non-VA treatment record did not show evidence of large vessel atherosclerosis, and the Veteran's impaired diastolic dysfunction resulted from age. The VA examination and medical opinion is highly probative because the examiner had an accurate and complete understanding of the Veteran's medical history and provided a medical conclusion with supporting rationale. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Veteran's cerebrovascular accident was not "chronic" because there were no manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time of service as evidenced by service medical examiners attributing the Veteran's in-service chest pain to heavy coffee consumption, strenuous work or exercise, and pneumonia. To the extent the Veteran contends that his in-service chest pain was a manifestation of his May 2018 cerebrovascular accident or any other heart disorder, the Veteran is not competent, as a lay-person, to provide a medical opinion as to the cause or attribute his symptoms to a diagnosis of cerebrovascular accident or any other heart disorder. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In addition, there was no continuity of symptomatology as evidenced by an absence of approximately 32 years of medical complaints pertaining to a heart disorder. Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (lengthy period of absence of medical complaints for condition can be considered as a factor in resolving the claim); Savage v. Gober, 10 Vet. App. 488, 496 (1997) (holding that symptoms, not treatment, are the essence of any evidence of continuity of symptomatology). A preponderance of the evidence is against a finding that the Veteran's heart disorder was incurred in or caused by exposure to herbicide agents during service in Vietnam. Service medical examiners attributed the Veteran's in-service chest pain to heavy coffee consumption, strenuous work or exercise, and pneumonia and there was an absence of approximately 32 years of medical complaints pertaining to a heart disorder. The December 2020 VA examiner opined that the Veteran's heart disorder was not caused by exposure to herbicide agents. Significantly, no competent medical provider has opined otherwise. Therefore, service connection is not warranted and the claim is denied. Vito A. Clementi Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Cohen, 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.