Citation Nr: 22016244 Decision Date: 03/21/22 Archive Date: 03/21/22 DOCKET NO. 17-58 850 DATE: March 21, 2022 ORDER Entitlement to service connection for a heart disorder is denied FINDING OF FACT A heart disorder was not shown in service or many years thereafter; the probative evidence fails to establish that the Veteran's diagnosed sinus node dysfunction is etiologically related to active service. CONCLUSION OF LAW The criteria for service connection for a heart disorder are not met. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty with the United States Army from May 1980 to October 1987 and from March 1988 to October 1989. This matter comes before the Board of Veterans' Appeals (Board) from a July 2017 rating decision by a Department of Veterans Affairs (VA) agency of original jurisdiction (AOJ). In May 2019, the Board denied this claim, and, in response, the Veteran appealed to the United States Court of Appeals for Veterans Claims (Court). In a March 2021 Memorandum Decision, the Court vacated the Board's decision denying these claims and remanded them back to the Board for readjudication and/or further development. In October 2021, the Board again remanded this matter for further development. Heart Disability The Veteran contends that his heart disability was caused or aggravated by his service. Specifically, the veteran contends that either his heart disability is etiologically related to his in-service chest pains or in the alternative his heart disability was related to electromagnet field (EMF) that he was exposed to during his service. Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1153; 38 C.F.R. §§ 3.303, 3.304, 3.306. In addition, valvular heart disease will be presumed to have been incurred in or aggravated by service if manifest to a degree of 10 percent or more within one year of a veteran's separation from service. 38 U.S.C. §§ 1101, 1110, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. With chronic diseases shows as such in service or within the presumptive period 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 clearly attributable to intercurrent causes. Continuity of symptomatology is required only where the condition noted during service or the presumptive period is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after service is required to support the claim. 38 C.F.R. § 3.303 (b). This regulation pertains to "chronic diseases" enumerated in 38 C.F.R. § 3.309 (a) (listing named chronic diseases). Walker v. Shinseki, 708 F.3d 1331, 1336-37 (Fed. Cir. 2013). The United States Court of Appeals for the Federal Circuit (Federal Circuit) noted that the requirement of showing a continuity of symptomatology after service is a "second route by which a veteran can establish service connection for a chronic disease" under subsection 3.303(b). Showing a continuity of symptoms after service itself "establishes the link, or nexus" to service and also "confirm[s] the existence of the chronic disease while in service or [during the] presumptive period." Id. (holding that section 3.303(b) provides an "alternative path to satisfaction of the standard three-element test for entitlement to disability compensation"). Service connection may also 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). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) 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). The Veteran's service treatment records reflect that in April 1981 he was seen for a complaint of midsternal chest pain; he was assessed with epigastric distress on April 12, 1981, and an EKG strip was noted to have no abnormalities. The next day he was assessed with probable chest well syndrome. In July 1981 and May 1988 Reports of Medical History, he denied pain or pressure in the chest, heart trouble, or palpitation or a pounding heart. However, an August 1987 Report of Medical History reflects that although he denied heart trouble, he reported having, or having had, pain or pressure in the chest; an x-ray for chest pain was negative. An August 1987 service treatment record reflect that he was assessed with chest wall pain/costochondritis. Another August 1987 service treatment record note that he had "noncardiac" chest pain. An August 1988 pre-op urology chest x-ray also reflects that the exam was unremarkable except for an old granulomatous disease. An August 1989 Report of Medical History reflects that he reported that he gets shortness of breath and chest pain when running PT (physical training). The corresponding Report of Medical Examination reflects a normal heart upon examination. An August 1989 Medical Evaluation Board (for a thumb disability) record reflects that his heart had a regular rate and rhythm with no murmur noted. In June 2017, the Veteran underwent a VA heart examination. The examiner diagnosed the Veteran with sinus node dysfunction status-post pacemaker placement. The examiner noted the date of the Veteran's diagnosis was in July 1997. During the examination the Veteran reported that during service he worked with generators and that he often slept next the units for long periods of time. The Veteran stated that in July 1997 he had a heart attack, and a pacemaker was placed. 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. The examiner determined that medical literature does not support a definite association between electromagnetic field exposure and cardiac arrhythmias. The examiner cited multiple studies finding no association between exposure to extremely low frequency magnetic fields and arrythmias, as well as a literature review that reached the same conclusion. In addition, the examiner noted that a 1999 study finding a possible association between occupational magnetic fields and arrythmia-related heart disease, referenced by the Veteran and his physician, was less comprehensive and featured less robust controls than a followup study finding no such association. In November 2021, a VA clinician offered an addendum opinion based on review of the claims file. The reviewer opined that it is less likely than not the Veteran's heart disability is related to his complaints of chest pain in-service. The examiner reasoned that the Veteran was found to have costochondritis and non-cardiac chest wall pain in-serve and these conditions do not lead to myocardial infarction or sick sinus syndrome. The examiner further reasoned that Veteran's condition may be caused by atherosclerosis, inflammatory process, or emboli; by other diseases of the heart or the medications used to treat them, and the most significant risk factor of the age. Further, the examiner explained there was no in-service event, illness or disease that would have led to the Veteran's development of myocardial infraction or sick sinus syndrome. The Board finds these two opinions were rendered following a complete review of the Veteran's claims file and contain thorough rationales for the conclusions; the Board considers both of the opinions to be competent and highly probative. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board notes a June 2017 private medical opinion linking the Veteran's heart disorder to service. The opinion is partially based on the aforementioned 1999 study submitted by the Veteran in April 2017. As previously discussed, the examiner indicated that a more rigorous followup study found no association between electromagnetic field exposure and arrythmia-related heart disease. The private opinion conflates the purported existence of an association/relationship between electromagnetic field exposure and cardiovascular mortality with the existence of a causal relationship. In addition, the opinion fails to address more recent medical literature cited in the VA opinion and references other supporting studies without further detail. For these reasons, the June 2017 private opinion is outweighed by the VA opinion. The Board finds that the Veteran has a current disability of sinus node dysfunction status-post pacemaker placement. The Veteran had in-service chest pain and exposure to running generators. The Veteran's DD-214 reflects a military occupational specialty of power generation equipment repairer. The lay assertions of being near power generators are facially plausible and consistent with the Veteran's military occupational specialty. However, the Board finds that the probative evidence is against a finding that the Veteran's condition began in-service or was caused or aggravated by his service. The Veteran's in-service chest pain was not cardiac and does not lead to the Veteran's sinus node dysfunction. The exposure to running generators did not cause or aggravate the Veteran's sinus node dysfunction because medical science does not support the idea that exposure to electromagnetic fields causes cardiac diseases. Therefore, service connection is not warranted. Service connection for the Veteran's heart condition on a presumptive basis is not warranted. The record indicates that he did not have any heart issues until 1997, nearly 10 years after his service. Further, no heart condition or symptom was noted in-service. As noted above, non-cardiac chest pain is not a sign or symptom of a heart disorder. The Veteran's representative argues that the November 2021 medical opinion is not adequate. The representative states that simply citing the medical evidence in the record is not an adequate rationale for a medical opinion. The representative also notes stated that the service treatment records do not contain any test that would diagnosis the Veterans condition and such tests are needed because costochondritis has similar symptoms as heart conditions. The Board considered these arguments; however, the arguments are factually inaccurate. While the November 2021 examiner did list the medical evidence, the examiner also explained why the Veteran's in-service chest pain is not related to his current heart disability. Further, the Veteran's service treatment records do include negative x-ray and EKG reports as noted above, contradicting the representative's argument that the Veteran did not undergo any test that could diagnosis his cardiac condition. The Veteran believes his heart conditions are related to an in-service injury, event, or disease. The Veteran in this case is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of pathology and interpretation of complicated diagnostic medical testing. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Accordingly, the evidence is persuasively against the claim. As there is not an approximate balance of positive and negative evidence, the benefit-of-the-doubt doctrine is not applicable and service connection for a heart disability is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. WILLIAM H. DONNELLY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Robert Batten 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.