Citation Nr: 22015791 Decision Date: 03/19/22 Archive Date: 03/19/22 DOCKET NO. 12-23 202 DATE: March 19, 2022 ORDER Service connection for a cardiovascular disability, other than supraventricular arrhythmia, to include left ventricular hypertrophy and diastolic dysfunction, to include as secondary to service-connected supraventricular arrhythmia, is denied. FINDING OF FACT A cardiovascular disability, other than supraventricular arrhythmia, was not present in service or for years thereafter, and is not etiologically related to service or a service-connected disability. CONCLUSION OF LAW The criteria for service connection for a cardiovascular disability, other than supraventricular arrhythmia, to include left ventricular hypertrophy and diastolic dysfunction have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from September 1970 to April 1972. The Veteran testified before the undersigned at a March 2015 Travel Board hearing. The hearing transcript is of record. In October 2015, January 2018, December 2019, and November 2021, the Board remanded the case for further development by the originating agency. The case has been returned to the Board for further appellate action. SERVICE CONNECTION Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. § § 1110; 38 C.F.R. § 3.303 (a). Establishing service connection generally requires (1) 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) medical 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 Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. 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). A disability which is proximately due to or the result of a service-connected disease or injury shall be service-connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310 (2019); see also Harder v. Brown, 5 Vet. App. 183, 187 (1993). In order to prevail on the issue of secondary service connection, the record must show: (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Where a veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic disabilities, including organic heart disease, to a degree of at least 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. Even though a disease is not included on the list of presumptive diseases, a nexus between the disease and service may nevertheless be established on the basis of direct service connection. Stefl v. Nicholson, 21 Vet. App. 120 (2007). When a claimed disability is not included as a presumptive disability, direct service connection may nevertheless be established by evidence demonstrating that the disability was in fact incurred during service. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of the matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § § 5107 (2012); 38 C.F.R. § 3.102 (2019); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. At 54. Service connection for a cardiovascular disability, other than supraventricular arrhythmia, to include left ventricular hypertrophy and diastolic dysfunction The Veteran contends that he has currently diagnosed cardiovascular disabilities, other than supraventricular arrhythmia, related to heart problems in service. A cardiovascular disability was not diagnosed until many years after service, and there is no competent evidence to establish that any current cardiovascular disability, other than supraventricular arrhythmia, is due to any event or incident of the Veteran's period of active duty or related to a service-connected disability. Service treatment records show the Veteran complained of chest pain and rapid heartbeat (arrhythmia) in December 1971. He was noted to have tachycardia, and coronary awareness was diagnosed. He complained of heart trouble and chest pain in January and February 1972, but was diagnosed with bronchitis at that time. VA treatment records dated many years after discharge show diagnoses and treatment for cardiovascular disabilities, including tachycardia, ischemic heart disease with myocardial infarction, supraventricular arrhythmia, left ventricular hypertrophy, and diastolic dysfunction. However, the evidence does not indicate that any currently diagnosed cardiovascular disability, other than supraventricular arrhythmia, is due to any event or incident of the Veteran's period of active duty or to a service-connected disability. In this regard, on February 2008 VA heart examination, the Veteran was diagnosed with tachycardia. At that time, the Veteran reported he was diagnosed with coronary artery disease four years prior. The examiner, a nurse practitioner, opined it would be speculation to relate the current tachycardia to the in-service tachycardia. He explained that stress can elevate a heart rate, but concluded that the etiology was unclear. He also indicated that an opinion regarding whether the tachycardia was related to heart disease would be based on speculation because heart disease was not diagnosed until four years prior to the examination. The Board notes that in a March 2008 and July 2009 rating decision, the RO found that the Veteran's current tachycardia was not related to service. See March 2008 and July 2009 rating decisions. On May 2011 VA heart examination, history of myocardial infarction in 2003 and ischemic heart disease were diagnosed. The Board notes that in a July 2021 rating decision, the RO found that the Veteran's ischemic heart disease with myocardial infarction is not related to service. See July 2021 rating decision. VA treatment records include a November 2011 VA echocardiogram that revealed Grade I diastolic dysfunction and a January 2012 EKG that revealed sinus tachycardia and left ventricular hypertrophy. Due to the conflicting medical evidence of record, the Board remanded the claim in October 2015 for another medical opinion regarding the nature and etiology of the Veteran's variously diagnosed cardiovascular disabilities. The examiner was requested to identify by diagnosis each cardiovascular disability shown. On February 2017 VA examination, acute, subacute, or old myocardial infarction was diagnosed. The Veteran reported he had a heart attack in 1971 while stationed in Germany. The examiner noted he was a nurse practitioner, not a cardiologist or internist, and did not provide an etiology opinion. On April 2017 VA examination, the examiner opined that "the records do not support the diagnosis of old myocardial infarction with a high degree of probability (>50%)." The examiner opined the documented sinus tachycardia is not an ongoing or chronic problem, but occurred in a setting of chest pain and was self-limiting. The examiner noted there was no current tachycardia and did not identify any other cardiovascular disabilities as shown. In a January 2018 remand, the Board found that the February 2017 VA examiner's opinion was not fully responsive to the questions presented and did not reflect contemplation of the entire record. Specifically, the examiner did not acknowledge and address a November 2011 VA echocardiogram that revealed Grade I diastolic dysfunction and a January 2012 EKG that revealed sinus tachycardia and left ventricular hypertrophy (the significance of which required explanation). As such, the Board remanded the claim again for an opinion that encompassed all evidence and included a complete rationale. The January 2018 Board remand sought a medical advisory opinion by an internist or cardiologist regarding the likely etiology for each cardiovascular disability the Veteran was found to have. If a cardiovascular disability was found to not have been incurred in service, the alternative etiology that is considered to be more likely was to be identified. On September 2019 VA heart examination, the initiating author is identified as Dr. N.B, an internist); however, the report was completed (and signed)by a "supervisor compensation and pension" (not seem to be a cardiologist or internist). Diastolic dysfunction and sinus tachycardia (noting the date of diagnosis was "during and after ms") were diagnosed; the likely etiology of all the diagnosed entities was not identified. While the examiner noted sinus tachycardia was diagnosed during and after military service, s/he opined (without rationale) that the current tachycardia "cannot be related" to military service. Additionally, the examiner did not comment on the prior VA examination reports. Accordingly, in December 2019, the Board found the September 2019 examination inadequate and remanded for an addendum opinion, consistent with the January 2018 remand directives. In accordance with the Board's December 2019 remand directives, addendum opinions were submitted in February 2020, August 2020, and October 2020, which were all found inadequate by the RO. See July 2020, September 2020, and October 2020 Deferred Rating Decisions. The Veteran was afforded another VA heart examination in November 2020. Supraventricular arrhythmia, left ventricular hypertrophy, and diastolic dysfunction were diagnosed. While the examiner provided a positive etiological opinion for supraventricular arrhythmia, the examiner opined that it is not known whether ventricular hypertrophy and diastolic dysfunction were present in service and opined it was less likely than not related to service. The examiner noted that a 2012 echocardiogram first demonstrated ventricular hypertrophy and diastolic dysfunction, but a 2020 echocardiogram did not find such abnormalities. The provider did not identify an alternative etiology for that ventricular hypertrophy and diastolic dysfunction that were found during the pendency of the claim. Accordingly, the Board remanded the claim again in November 2021 for a fully adequate medical opinion, consistent with the Board's December 2019 remand directives. The November 2021 Board remand sought a medical advisory opinion by an internist or cardiologist regarding the likely etiology for each cardiovascular disability, other than supraventricular arrhythmia, diagnosed during the pendency of the appeal. If a cardiovascular disability other than supraventricular arrhythmia was found to not have been incurred in service, the examiner was directed to opine whether it was caused or aggravated by the Veteran's service-connected supraventricular arrhythmia. Furthermore, if a cardiovascular disability other than supraventricular arrhythmia was determined to be unrelated to the Veteran's service and to not have been caused by a service-connected disability, the alternative etiology that is considered to be more likely was to be identified. In accordance with the Board's November 2021 remand directives, the Veteran was afforded another VA heart examination in December 2021. The examiner opined that the currently diagnosed cardiovascular disabilities were less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that although diastolic dysfunction and cardiac hypertrophy were reported in 2012, the Veteran had an echocardiogram in December 2020, and there was no evidence of these disabilities. The examiner noted further that it is common medical knowledge that if one has diastolic dysfunction or cardiac hypertrophy these conditions do not resolve. As such, the examiner concluded that it is less likely than not that these conditions are related to the Veteran's active duty service. The examiner also noted that it is clear that the Veteran was seen for chest pain while in Germany in 1971. Records further indicate that in March 1971, he was admitted to Holy Cross Hospital for chest pain. However, he had an EKG completed in January 2021 that shows no evidence of left ventricular hypertrophy, and no evidence of previous myocardial infarction. A December 2020 echocardiogram was completely normal. There was no evidence of diastolic dysfunction or left ventricular hypertrophy. Medically speaking, the examiner noted, the best way to diagnose diastolic dysfunction and left ventricular hypertrophy is with an echocardiogram. The examiner also opined that, as the Veteran currently does not have a diagnosis of diastolic dysfunction or left ventricular hypertrophy, neither disability was caused or aggravated by the service-connected supraventricular arrhythmia. With regard to the likely etiology of the claimed cardiovascular disabilities, the examiner concluded that such an opinion could not be provided without resort to speculation. The examiner explained that, as sinus arrhythmias are generally benign conditions that have very nonspecific etiologies, which include endocrine neuropathies, stress, deconditioning and congenital causes, it is impossible to opine on the etiology of such disabilities without speculation. The RO found that the December 2021 opinion was lacking, in that the examiner did not give an opinion on the etiology of the left ventricular hypertrophy and diastolic dysfunction diagnosed earlier in the appeal periodin 2012. Accordingly, an addendum to the opinion was submitted in December 2021 by the same examiner. The examiner concluded that the medical records do not support that the currently diagnosed left ventricular hypertrophy and left diastolic dysfunction were caused by the heart problems during service. The examiner explained that during service, the Veteran was hospitalized and evaluated for injuries sustained after getting kicked in the chest. Records indicate that that particular incident was a self-limiting chest wall injury, and there is no evidence of any cardiac disease. It is noted that the Veteran was evaluated for chest pain and completed an echocardiogram in 2012 that demonstrated mild diastolic dysfunction with some left ventricular hypertrophy. This is 30 years after separation from the military service. Current echocardiogram dated in December 2020 shows no evidence of either diastolic dysfunction or left ventricular hypertrophy. The examiner also noted that diastolic dysfunction and left ventricular hypertrophy are conditions that cannot resolve, and therefore, the examiner opined that the echocardiogram completed in 2012 is less likely to be an accurate assessment of the Veteran's cardiac status at that time. The examiner noted further that technology has progressed significantly in the past few years with regard to the diagnosis of left ventricular hypertrophy and diastolic dysfunction. He concluded that the examination completed in 2012 more than likely was a borderline diagnosis of left ventricular hypertrophy and diastolic dysfunction. The examiner also opined that the etiology of the diagnosis provided by the echocardiogram of 2012 is more than likely due to aging. The Board notes that service connection is possible for disabilities first diagnosed after service, and the lack of evidence of a disorder in the service treatment records is not fatal to a claim for service connection. However, given the lack of evidence of a cardiovascular disability, other than arrhythmia and tachycardia, during active duty, the lack of evidence of a cardiac disability at discharge, and the decades-long gap between service and the first notation of a cardiovascular disability, the Board does not find the Veteran's current accounts of a cardiovascular disability, other than supraventricular arrhythmia, since service to be credible. As such, the Board finds that the December 2021 VA examiner's addendum opinion is supported, and another examination is not necessary. The Board also notes that the December 2021 examiner, in his original opinion, did not discuss whether the diastolic dysfunction and left ventricular hypertrophy diagnosed in 2012 were caused or aggravated by the service-connected supraventricular arrhythmia. However, in the addendum opinion, the examiner concluded that the 2012 diagnoses were likely just borderline, and as such, an opinion on the relationship of such claimed disabilities to the service-connected supraventricular arrhythmia is not required, and this portion of the December 2021 examiner's original opinion is supported, and another examination is not necessary. There is no conflicting medical opinion of record. Furthermore, there is no other evidence, VA or private, which indicates that the Veteran's cardiovascular disabilities, other than supraventricular arrhythmia, may be related to his active military service or a service-connected disability. With regard to the years-long evidentiary gap in this case between active service and the earliest manifestations of a cardiovascular disability, the Board notes that this passage of time weighs significantly against a finding of direct service connection for a cardiovascular disability, other than supraventricular arrhythmia. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The Board acknowledges the Veteran's assertion that he has a cardiovascular disability, other than supraventricular arrhythmia, due to events during his active service. The Veteran is competent to report the observable symptoms of a disability, and in certain situations a lay person may be competent to establish the etiology of a disability. However, the Board finds that in the present case, the Veteran is not competent to provide a nexus between a currently diagnosed a cardiovascular disability, other than supraventricular arrhythmia and his active service or events therein, or a currently diagnosed a cardiovascular disability, other than supraventricular arrhythmia and a service-connected disability, as it would require medical expertise to say that a current a cardiovascular disability, other than supraventricular arrhythmia, identified after service, is the result of an in-service disease or injury or a service-connected disability. The Veteran, as a layperson, is not qualified to render an opinion concerning the medical cause of his cardiovascular disability. 38 C.F.R. § 3.159 (a)(1), (2). There is no competent evidence relating a current a cardiovascular disability, other than supraventricular arrhythmia, to any event in his active service or to a service-connected disability. Absent such evidence, the Veteran's claim must be denied. In reaching this decision, the Board has considered the benefit-of-the-doubt doctrine; however, as the evidence is persuasively against the claim and the positive and negative evidence is not nearly in balance, that doctrine is not applicable. KELLI A. KORDICH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board F. Yankey, 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.