BVA9502769 DOCKET NO. 93-09 823 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUES 1. Entitlement to service connection for myocardial infarctions. 2. Entitlement to an increased rating for peptic ulcer disease, currently evaluated as 20 percent disabling. REPRESENTATION Appellant represented by: Alvin D. Wax, Attorney WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Robert E. P. Jones, Associate Counsel INTRODUCTION The veteran served on active duty from May 1967 to January 1969. This matter came before the Board of Veterans' Appeals (Board) on appeal from a June 1992 rating decision by the Louisville, Kentucky, Regional Office (RO). In a substantive appeal received in April 1993, the veteran raised the issues of entitlement to service connection for an anxiety disorder and to a total rating due to individual unemploy- ability. These issues are referred to the RO for appropriate action. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that he is entitled to service connection for his myocardial infarctions. He asserts that they were caused by blood clots from his service-connected left axillary vein thrombosis. He also asserts that his myocardial infarctions might have been avoided if he could have used blood thinners which he was unable to use due to his service-connected peptic ulcer disease. The veteran also contends that he is entitled to an increased rating for peptic ulcer disease. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the veteran's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the preponderance of the evidence is against the claims for service connection for myocardial infarctions and an increased rating for peptic ulcer disease. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the veteran's appeal has been obtained. 2. Heart disease was not present in service or manifested until many years after discharge from service; it is not shown that the veteran's heart disease with myocardial infarctions is related to service or was proximately caused by either his service-connected left axillary vein thrombosis or his service-connected peptic ulcer disease. 3. The veteran's peptic ulcer disease is no more than moderate in degree. CONCLUSIONS OF LAW 1. The veteran's heart disease with myocardial infarctions was not incurred or aggravated in service, may not be presumed to have been incurred in service, and is not proximately due to or the result of his service-connected left axillary vein thrombosis or peptic ulcer disease. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 1991); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310(a) (1994). 2. The criteria for an evaluation in excess of 20 percent for peptic ulcer disease are not met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.7, 4.114, Code 7305 (1994). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS We note that we have found that the veteran's claims are "well grounded" within the meaning of 38 U.S.C.A. § 5107(a). That is, we find that he has presented claims which are plausible. We are also satisfied that all relevant facts have been properly developed and that no further assistance to the veteran is required to comply with the duty to assist mandated by 38 U.S.C.A. § 5107(a). The veteran's service medical records and his discharge physical examination of January 1969 are silent as to symptoms or findings of cardiovascular disease. These records do show blood pressure readings of 138/88 in May 1967, prior to induction, 130/80 in September 1967, and 138/90 in January 1969. These readings were not considered abnormal. Hypertension or cardiovascular disease was not diagnosed in service. The first record of chest pain is a February 1976 private hospital record showing a nine-day inpatient treatment for complaints of chest pain and shortness of breath. The veteran was found to have an ulcer, and his symptoms were believed to be due to his ulcer. On Department of Veterans Affairs (VA) examination in July 1985, the veteran was noted to have mild hypertensive vascular disease. On VA vascular and gastrointestinal examinations in May 1987, no cardiovascular disease was noted. Private medical records reveal that the veteran had cardiac catheterizations in July 1987, September 1987, April 1989, and June 1990. In June 1980, he experienced an acute inferior wall myocardial infarction. He experienced another myocardial infarction in March 1992. Cardiac catheterizations were again performed in March and April 1992. At a hearing at the RO in September 1992, the veteran testified that he had had two myocardial infarctions due to his service- connected axillary vein thrombosis. It was his belief that the myocardial infarctions had been caused by blood clots stemming from his left axillary vein thrombosis. He also related his myocardial infarctions to his service-connected peptic ulcer disease. He believed that treatment for his peptic ulcer disease prevented the use of blood thinners when he was treated for his myocardial infarctions. The veteran said that he would obtain a statement from his physician that his heart attacks were secondary to his left axillary vein thrombosis. A letter was received from the veteran's physician in October 1992. Steven H. Smoger, M.D., stated that the veteran had serious coronary artery disease. He reported that the veteran had had myocardial infarctions in June 1990 and March 1992. It was Dr. Smoger's opinion that the veteran qualified for disability benefits based on the extent of his cardiac history. Dr. Smoger did not comment on a causal connection between the veteran's myocardial infarctions and any of his service-connected disabilities. The veteran received a VA cardiac examination in November 1992. The impression included coronary artery disease and history of three myocardial infarctions. The VA examiner noted that it was possible that the veteran's myocardial infarctions might have been exacerbated by easier than normal thrombogenic potential of the atherosclerotic plaques, but that there was no proof of that. A September 1967 service medical record reveals a complaint of swelling in the left arm and a finding of axillary vein thrombosis. On VA examination in July 1985, the veteran reported that he experienced a blood clot of his left arm in the axillary vein in 1967 when a machine gun was dropped on it. Examination revealed that the left axillary vein was more prominent, but the veteran only had minimal residuals. The veteran received a VA examination in May 1987. Examination of the left extremity revealed decreased sensation in the left hand. The deep venous return of the left upper extremity appeared to be slightly diminished. The examiner noted past history of left axillary vein thrombosis with moderately severe residuals. VA examination report in November 1992 includes an impression of history of left axillary vein thrombosis. Since a cardiovascular disorder was not present during service or within one year following the veteran's discharge from service and the requisite nexus to service is not demonstrated, service connection for myocardial infarctions on a direct basis or on the basis of presumed incurrence in service is not warranted. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113 (West 1991); 38 C.F.R. §§ 3.303, 3.307, 3.309. Secondary service connection for a disability is warranted if the disability is proximately due to or the result of a service- connected disease or injury. 38 C.F.R. § 3.310(a). While the veteran believes that his heart attacks were caused by blood clots from his left axillary vein thrombosis, he lacks the medical expertise or knowledge to offer a probative opinion regarding the etiology of his condition. Espiritu v. Derwinski, 2 Vet.App. 492 (1992). The claims file contains numerous private treatment records reflecting treatment for cardiovascular disease, including two myocardial infarctions. None of these records relate the development of the veteran's cardiovascular disease or the development of his myocardial infarctions to his left axillary vein thrombosis. Nor did the VA examiner of November 1992 find the left axillary vein thrombosis to be the proximate cause of the veteran's myocardial infarctions. Furthermore, the evidence of record does not relate the treatment of the veteran's peptic ulcer disease to his development of heart disease and resultant myocardial infarctions. The veteran's testimony claiming such relationships may have been sincere. But it is not probative of his claim because he lacks the medical expertise to provide an opinion which is competent evidence on this claim. Consequently the Board finds that service connection for myocardial infarctions is not warranted on a secondary basis. The evidence is not so evenly balanced that there is doubt as to any material issue. 38 U.S.C.A. § 5107. II. The veteran also seeks an increased rating for his peptic ulcer disease. He developed peptic ulcer disease in service. He was hospitalized and treated for an antral ulcer in February 1976. On VA hospitalization for treatment of hypertension in June 1985, it was noted that the veteran had been diagnosed as having severe peptic ulcer disease in 1977 and had been treated with Tagamet. X-rays in June 1985 revealed no peptic ulcer disease or other discernible gastrointestinal lesions. VA examination of the veteran in July 1985 was normal except for minimal to moderate epigastric tenderness. The veteran was granted service connection and a 10 percent disability evaluation for peptic ulcer disease in a January 1986 rating action. An upper gastrointestinal series at a VA medical center in April 1987 revealed a hiatal hernia and gastroesophageal reflux. VA examination of May 1987 produced a diagnosis of history of peptic ulcer disease. Based on this examination, the veteran's disability evaluation for peptic ulcer disease was reduced to noncompensable in a July 1987 rating decision. An August 1990 letter from Dr. Smoger notes that he treated the veteran for an acute upper gastrointestinal hemorrhage related to peptic ulcer disease during June and July 1990. Dr. Smoger stated that the veteran had recovered quite well but that he required ongoing observation and therapy. Esophagogastroduodenoscopy (EGD) in August 1990 revealed erosion and scarring of the duodenal bulb and prepyloric erosions with superficial ulcerations. The veteran's disability evaluation was restored to 10 percent in a January 1991 rating action. At the September 1992 hearing before a hearing officer, the veteran testified to having frequent stomach pain due to ulcer disease. He reported taking Zantac to get some relief from the pain. He stated that the attacks could last from half an hour to two days in length. The veteran was afforded a VA gastrointestinal examination in November 1992. He complained of epigastric pain, heartburn, and reflux symptoms, but denied weight loss. On examination, his abdomen was soft and nontender. Rectal examination was negative. EGD revealed evidence of erosive antritis with several small erosions. No overt ulcerations were noted, and the duodenal bulb appeared normal. Based on this examination and the other evidence of record, the RO granted an increased rating of 20 percent, effective from May 1992. A rating in excess of 20 percent requires that the ulcer disease be moderately severe, with impairment of health, manifested by anemia and weight loss or recurrent incapacitating episodes averaging 10 days or more at least four or more times a year. 38 C.F.R. § 4.114, Code 7304. The veteran's testimony and the VA examination of November 1992 do not reveal such severe symptoms. There is no evidence that the ulcer disease causes anemia or weight loss or produces incapacitating episodes lasting 10 days or more in duration. Consequently, an increased rating for peptic ulcer disease is not warranted. In reaching its decision, the Board has considered the complete history of the disability in question as well as the current clinical manifestations and the effect the disability may have on the earning capacity of the veteran. 38 C.F.R. §§ 4.1, 4.2 (1994). Further, the Board finds that in this case the disability picture is not so exceptional or unusual so as to warrant an evaluation on an extraschedular basis. It has not been shown that peptic ulcer disease has resulted in frequent hospitalization or causes marked interference with employment. 38 C.F.R. § 3.321(b)(1) (1994). The criteria for an evaluation greater than 20 percent have not been met or approximated. 38 C.F.R. § 4.7. The evidence is not so evenly balanced that there is doubt as to any material issue. 38 U.S.C.A. § 5107. ORDER Service connection for myocardial infarctions is denied. An increased rating for peptic ulcer disease is denied. GEORGE R. SENYK Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals.