Citation Nr: 21036655 Decision Date: 06/15/21 Archive Date: 06/15/21 DOCKET NO. 17-26 926 DATE: June 15, 2021 ORDER Entitlement to service connection for heart murmur, secondary to service-connected degenerative joint disease of the left knee with instability and limited extension (left knee disability) on a causation basis, is granted. Entitlement to service connection for hypertension, secondary to service-connected left knee disability on a causation basis, is granted. REMANDED Entitlement to service connection for ischemic heart disorder (IHD) is remanded. FINDINGS OF FACT 1. The evidence is evenly balanced as to whether the Veteran's heart murmur is a result of his service-connected left knee disability. 2. The evidence is evenly balanced as to whether the Veteran's hypertension is a result of his service-connected left knee disability. CONCLUSIONS OF LAW 1. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for heart murmur, secondary to left knee disability, have been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.310. 2. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for hypertension, secondary to left knee disability, have been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1974 to October 1977. This case comes before the Board of Veterans' Appeals (Board) on appeal from a July 2012 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO), which, among other things, denied service connection for hypertension and heart murmur (claimed as heart disorder). In May 2013 the Veteran filed a notice of disagreement (NOD), in March 2017 the RO issued a statement of the case (SOC), and in May 2017 the Veteran filed a substantive appeal (via VA Form 9). In September 2020 the Board remanded the Veteran's claim for additional development. As will be discussed below, the RO did not substantially comply with the September 2020 remand instructions with regard to the claim for service connection for IHD and another remand is therefore required. Stegall v. West, 11 Vet. App. 268 (1998). As a final preliminary matter, in Clemons v. Shinseki, 23 Vet. App. 1, 4-5 (2009) the Court held that a claim should not be limited to the disorder as characterized by the Veteran, but must be characterized and addressed based on the reasonable expectations of the non-expert claimant and the evidence in processing the claim. The Veteran originally filed a claim for heart disorder and the Board has broadened the Veteran's claim and considered all cardiac disabilities raised by the record. As will be discussed below, the Board is granting service connection for a heart murmur and is separately remanding the claim for service connection for IHD. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service incurrence of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a),(b). 1. Hypertension and cardiac murmur The Veteran contends that his hypertension and heart disorder, to include a heart murmur, are caused by his use of non-steroidal anti-inflammatory drugs (NSAIDs) for his service-connected left knee disability. This is a valid theory of entitlement. Velez v. West, 11 Vet. App. 148, 157 (1998) (discussing "an implicit secondary-service-connection claim that his gastrointestinal disorder was the result of, inter alia, pain medication taken for his service-connected right-shoulder condition"). An August 2010 private physician found abnormal findings with his heart such as systolic wall thickening and qualitative perfusion images. The private physician diagnosed the Veteran with a heart murmur. A May 2012 VA examiner did not diagnose the Veteran with a heart condition, but instead noted the Veteran's heart sound was abnormal and diagnosed a heart murmur. In a March 2014 letter, the Veteran's private physician stated that he diagnosed the Veteran with hypertension and a cardiac murmur. Thus, the Veteran meets the current disability requirement. The remaining question is whether the Veteran's use of NSAIDs to treat his service-connected left knee disability caused his hypertension and heart murmur. A May 2012 VA examiner opined that the Veteran's heart condition is not caused by the medication he takes for his knee condition. The VA examiner also opined that the Veteran's hypertension is not caused by the medication he takes for his knee condition as they are not directly correlated. The VA examiner then stated that there is an indirect correlation if the patient is not able to maintain his weight because of his knee pain. In September 2013 the Veteran submitted articles from medical doctors regarding the relationship between the use of NSAIDs and hypertension as well as various cardiovascular effects. Generally, these articles indicate that hypertension and cardiovascular effects may be risk factors when taking NSAIDs. Medical article and treatise evidence "can provide important support when combined with an opinion of a medical professional." Sacks v. West, 11 Vet. App. 314, 317 (1998). Although the medical literature submitted by the Veteran is somewhat speculative, these articles are entitled to some probative weight. In a March 2014 letter, the Veteran's private physician opined it is as likely as not that the Veteran's use of NSAIDs caused his cardiac murmur and hypertension. The private physician explained that the medical literature and journals are replete with medical information and documentation that support this connection. While the private physician relied on the service history provided by the Veteran, the discounting of a medical opinion that relied on service history provided by the Veteran is only warranted in certain circumstances, none of which are present here. See Coburn v. Nicholson, 19 Vet. App. 427, 432-433 (2006) (reliance on the service history provided by the veteran only warrants the discounting of a medical opinion in certain circumstances, such as when the opinions are contradicted by other evidence in the record or when the Board rejects the statements of the veteran). Although the private physician's rationale was not extensive, reading the opinion as a whole and in the context of the evidence of record, it is entitled to some probative weight. See Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (the fact that the rationale provided by an examiner "did not explicitly lay out the examiner's journey from the facts to a conclusion," did not render the examination inadequate); Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012) (medical reports must be read as a whole and in the context of the evidence of record). A March 2017 VA examiner opined it is less likely than not that the Veteran's hypertension is due to his obesity from inactivity from his service-connected left knee condition. The VA examiner explained that the Veteran was not obese when he was diagnosed with hypertension. Also, the VA examiner stated that weight gain is multi-factorial and inactivity is not a direct cause of weight gain. The VA examiner stated that more common risk factors that are not modifiable include age, diet, and heredity. A January 2021 VA examiner opined it is less likely than not that the Veteran's heart condition or hypertension were aggravated beyond their natural progression because of his use of NSAIDs. The VA examiner explained that the Veteran has a history of hyperlipidemia which is associated with his family history. Also, the VA examiner pointed to the Veteran's test results at the May 2012 VA examination which were normal and without any antihypertensive medical therapy. The VA examiner noted that the Veteran did not experience significant cardiac symptoms during his METs (metabolic equivalents of task) test. A March 2021 VA examiner opined that the Veteran's cardiac murmur is less likely than not secondary to his use of NSAIDs for his left knee disability. The VA examiner noted that the Veteran was prescribed both steroids and nonsteroidal medications for his non-service connected nasal disability. He also noted that the Veteran had a longstanding history of hyperlipidemia which is in his family history. The VA examiner explained that medical literature does not establish a relationship between the use of NSAIDs and a heart murmur. The VA examiner explained that heart murmurs are typically a genetic/congenital condition which are not predisposed by outside factors. The March 2021 VA examiner also opined that the Veteran's hypertension is less likely than not secondary to his use of NSAIDs for his left knee disability. The VA examiner explained that chronic heavy use of NSAIDs can represent a risk factor for hypertension, however, stated that there is no evidence that the Veteran's use of NSAIDs was excessive or otherwise deviated from the normal standard of care. Also, the VA examiner explained that hypertension is an exceedingly common condition which typically occurs without any specific predisposing etiology. The Board finds the January and March 2021 VA opinions probative as they are clearly stated and supported by thorough rationales. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). However, the Board finds the positive nexus opinion and treatise evidence provided by the Veteran to be equal in probative weight to the negative nexus opinions provided by the March 2017 and March 2021 VA examiners. Therefore, the evidence is at least evenly balanced as to whether the Veteran's hypertension and heart murmur are proximately due to or the result of his use of NSAIDs for his service-connected left knee disability. Accordingly, service connection for hypertension and heart murmur, secondary to service-connected left knee disability, on a causation basis, is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 3.310. REASONS FOR REMAND Entitlement to service connection for IHD is remanded. A September 2019 surgical report indicates that the Veteran was diagnosed with new cardiomyopathy with abnormal stress test showing inferior infarct. A private surgeon performed left heart catheterization and coronary angiography on the Veteran. In a January 2020 letter, the Veteran's private physician confirmed that the Veteran was diagnosed with IHD. In a March 2014 letter, the Veteran's private physician found that his heart murmur was caused by him using NSAIDs to treat his left knee disability. In March 2014 the Veteran was not diagnosed with IHD or any cardiovascular disorders other than a heart murmur. Therefore, this opinion cannot serve as a basis for a grant of service connection for anything but the Veteran's heart murmur as this was the only cardiovascular issue the private physician addressed. In a January 2020 letter, the Veteran's private physician stated that his IHD may be related to long term Motrin usage and other NSAIDS. The private physician's use of the term "may," is stated in terms that are too uncertain to warrant probative weight and cannot serve as a basis to grant service connection. Hood v. Shinseki, 23 Vet. App. 295, 298-99 (2009) (medical opinion is speculative when it uses equivocal language such as "could" or "might," without any other rationale or supporting data); Polovick v. Shinseki, 23 Vet. App. 48, 54 (2009) (doctor's statement that veteran's brain tumor "may well be" connected to Agent Orange exposure was speculative); Bloom v. West, 12 Vet. App. 185, 187 (1999) (use of term "could," without other rationale or supporting data, is speculative); Goss v. Brown, 9 Vet. App. 109, 114 (1996) (use of the phrase "could not rule out" was too speculative to establish medical linkage). The March 2021 VA examiner opined that the Veteran's IHD is less likely than not secondary to his use of NSAIDs to treat his left knee disability. The VA examiner explained that NSAID use is not an established primary etiology of IHD in the medical literature and that his IHD is more likely secondary to the longstanding history of hyperlipidemia and/or family history. The Board notes that NSAID used does not have to be the primary etiology of IHD in order to satisfy the secondary service connection criteria, it need only be a cause of the Veteran's disability. As the VA examiner's opinion is not supported by a thorough rationale, the Board finds his opinion inadequate and another VA medical opinion is warranted. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide an examination or obtain a medical opinion, it must ensure that the examination or opinion is adequate). The matters are REMANDED for the following action: Request an opinion from an appropriate physician to determine the etiology of the Veteran's IHD. If an examination is deemed necessary, one should be conducted, include via telehealth if warranted. The physician should opine whether the Veteran's IHD is either (i) caused or (ii) aggravated by his use of NSAIDs for service-connected left knee disability or any other service-connected disability. The NSAID's need not be the sole or primary cause of the IHD, the question is only whether it is a cause of the IHD or it aggravates the IHD. If aggravation is found, the baseline of the IHD prior to aggravation should be identified, if possible. The physician should review the claims file prior to rendering the opinion and a complete rationale should accompany each opinion provided. The physician is advised that the Veteran is competent to report symptoms and treatment, and that his reports must be taken into account in formulating the requested opinion. Jonathan Hager Veterans Law Judge Board of Veterans' Appeals Attorney for the Board James R. Miller, 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.