Citation Nr: 0000797 Decision Date: 01/11/00 Archive Date: 01/27/00 DOCKET NO. 98-05 222 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUE Entitlement to service connection for a cardiovascular disorder, claimed as secondary to service-connected anxiety reaction manifested by hyperventilation and cardiac neurosis. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Robert W. Legg, Associate Counsel INTRODUCTION This matter comes before the Board of Veterans' Appeals (BVA or Board) from a March 1997 decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana, which denied the benefit sought on appeal. The veteran, who had active service from February 1953 to January 1955, appealed that denial, and the case was referred to the Board for appeal. FINDINGS OF FACT 1. Service connection has been established for an anxiety reaction manifested by hyperventilation and cardiac neurosis. 2. The veteran has been diagnosed with hypertension and premature atrial contractions. 3. The medical evidence incorporated in the claims file reflects that there is no relationship between the veteran's service-connected anxiety reaction manifested by hyperventilation and cardiac neurosis and any current organic cardiovascular disorder. CONCLUSION OF LAW Neither hypertension nor premature atrial contractions are the result of service anxiety reaction manifested by hyperventilation and cardiac neurosis. 38 U.S.C.A. §§ 1110, 5107 (West 1991); 38 C.F.R. §§ 3.102, 3.303, 3.310(a) (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by a veteran's active service or for a disability proximately due to, or the result of, a service-connected disability. See 38 U.S.C.A. §§ 1110, 1131 (West 1991); 38 C.F.R. §§ 3.303, 3.310(a) (1999). Where a veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, and cardiovascular disease becomes manifest to a degree of ten percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1110, 1112, 1113 (West 1991); 38 C.F.R. §§ 3.307, 3.309 (1999). The veteran's claim for service connection for a cardiovascular disorder, claimed as secondary to service-connected anxiety reaction manifested by hyperventilation and cardiac neurosis, is well- grounded within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). That is, the Board finds that the veteran has presented a claim which is plausible. Although the RO apparently concluded otherwise after what appears to be a comprehensive review of the evidence, the Board finds that the veteran has been given adequate notice of the need to submit evidence or argument on the underlying issue in this case and has been afforded the opportunity to submit evidence and argument on the underlying issue. See Bernard v. Brown, 4 Vet. App. 384 (1993). The Board is also satisfied that all relevant facts have been properly developed. No further assistance to the veteran is required to comply with the duty to assist mandated by 38 U.S.C.A. § 5107(a). Murphy v. Derwinski, 1 Vet. App. 78 (1990); Littke v. Derwinski, 1 Vet. App. 90 (1990). The veteran's claims file contains several references to ongoing psychiatric difficulties. A September 1951 pre- induction examination report noted that the veteran had an immaturity reaction that was characterized as mild. In August 1953, the veteran complained of dizziness, stiffness of his face, paresthesia, difficulty catching his breath, and of having a pounding heart. Examination revealed a blood pressure reading of 140/80. Heart examination at the time was reported to be negative. The impression was hyperventilation syndrome. In November 1953, he was seen for complaints of dizziness and weakness, and subsequent examination again revealed no evidence of organic cardiovascular disease. One impression in November 1953 was that the veteran's complaints were of a psychogenic basis. A December 1953 social history noted that the veteran had complaints related to weakness, insomnia and headaches. The veteran related that his nervousness began during basic training, when he fell over a footlocker while wrestling in the barracks and purportedly sustained a slight injury to his back. A June 1963 rating decision granted service connection for an anxiety reaction manifested by hyperventilation and cardiac neurosis (anxiety reaction). The veteran was assigned a 50 percent disability evaluation for this disability. In doing so, the RO relied on a January 1963 discharge summary from the VA Medical Center in Ann Arbor, which noted a pulse of 100 and a somewhat accentuated P-2 sound. A cardiologist did not believe that the veteran had heart disease based on extensive testing and evaluation. The diagnoses were anxiety reaction, hyperventilation syndrome, and cardiac neurosis. A February 1966 rating decision reduced the disability evaluation to 30 percent. A May 1966 rating decision continued that evaluation, and that decision was upheld in an April 1967 Board decision. The 30 percent evaluation has continued to date. The veteran filed this current claim in December 1996. He asserts that he has a cardiovascular disorder that is the result of his service-connected anxiety reaction. In this respect, he does not argue, nor does the record reflect, that he had an underlying pathological cardiovascular disorder in service or within one year following separation, thereby providing for presumptive service connection. 38 C.F.R. §§ 3.307, 3.309; Traut v. Brown, 6 Vet. App. 498, 502 (1994). Relevant evidence obtained during the course of this claim includes an April 1996 emergency department record from St. Joseph's Medical Center in South Bend, Indiana. At that time, the veteran's chief complaint was that his heart was skipping beats. The veteran's pulse was 96 beats per minute, and his initial blood pressure reading was 226/96; ten minutes thereafter, his blood pressure was 164/76. Objectively, the veteran's heart had a regular rate and rhythm, without murmur, but premature atrial contractions were noted. An EKG was abnormal; there was some evidence of an old inferior wall myocardial infarction. A follow-up exercise EKG noted that the veteran had a left anterior hemiblock. In correspondence dated May 1996, the veteran's cardiologist informed his family practitioner that while the EKG showed possible old myocardial damage, a more likely explanation was premature atrial contractions. The RO afforded the veteran a VA examination in February 1997. During the psychiatric portion of the examination, the veteran related that his problems originated when he fell in basic training and then developed nervousness, with an increased heart rate, shortness of breath and neck pain. Since then, the veteran continued, he had used Librium. The veteran was also afforded a cardiovascular examination. His blood pressure was 168/88, and his pulse was 89 beats per minute and regular. Heart tones were characterized as normal, and his heart had a regular rate and rhythm. The examiner reviewed the initial April 1996 EKG, and stated that the interpretation was inaccurate: there was no evidence of a previous infarction. In summary, this examiner stated that while systolic blood pressure was elevated there was no evidence of heart disease, and that an irregular heartbeat, standing alone, is not heart disease. In March 1997, however, the VA provided the veteran with a battery of tests. An echocardiogram showed that the veteran had left ventricular hypertrophy and dilation with decreased left ventricular systolic function; mild global hypokinesis with posterior and septal akinesis; and left atrial dilation. Another test reflected fixed defects involving the septum, compatible with infarction. The same examiner who performed the February 1997 examination again performed an April 1998 cardiovascular examination. The veteran's history and current medications were reviewed, as were his chief complaints of irregular heart rhythm and dyspnea with exertion. The examiner stated that the premature heartbeats had no relationship with his service- connected anxiety disorder or its manifestations of cardiac neurosis or hyperventilation. Further, the examiner stated that the irregular heart rhythm was not aggravated by service or any service-connected disability. Rather, referencing other opinions in the file, the examiner stated that record indicated that the veteran had a history of previous arrhythmia or premature atrial beats which had been corrected by eliminating caffeine. The veteran also submitted a VA outpatient treatment record dated in June 1998 in which the examiner appears to opine that the veteran's anxiety aggravated the veteran's hypertension which in turn aggravated the veteran's ischemic heart disease. After the receipt of the above opinion, the veteran was afforded another comprehensive VA examination. A different examiner conducted the final VA examination in October 1998. He noted that the veteran had been noted to have premature atrial contractions via an echocardiogram, and that the veteran had had complaints of an irregular heartbeat. The examiner noted that one of the veteran's medications was a beta blocker, and the use of Librium for his service- connected anxiety disorder was also noted. A history of hypertension was noted, and blood pressure was 160/84. Objectively, the veteran's heart displayed a regular rate and rhythm, and the examiner could not appreciate a mid-systolic click. Extremities showed trace edema. As to organic heart disease, the examiner stated that premature atrial complexes did not constitute organic heart disease, and further, such was not related to the veteran's service-connected anxiety disorder. That examiner also noted that patients with an anxiety disorder would have frequent symptoms of palpitations and diaphoresis, which would not necessarily correlate with an underlying coronary artery or heart disease, or to an underlying arrhythmia. Looking at the veteran in particular, the examiner diagnosed the veteran with premature atrial contractions, and that an etiology other than an organic heart disease should be considered. The evaluation of the same disability under various diagnoses is to be avoided. Disability from injuries to the muscles, nerves, and joints of an extremity may overlap to a great extent, so that special rules are included in the appropriate bodily system for their evaluation. Dyspnea, tachycardia, nervousness, fatigability, etc., may result from many causes; some may be service connected, others, not. Both the use of manifestations not resulting from service-connected disease or injury in establishing the service-connected evaluation, and the evaluation of the same manifestation under different diagnoses are to be avoided. 38 C.F.R. § 4.14. When a single disability has been diagnosed both as a physical condition and as a mental disorder, the rating agency shall evaluate it using a diagnostic code which represents the dominant (more disabling) aspect of the condition. 38 C.F.R. § 4.126(d). The Board notes that the veteran has been diagnosed with hypertension during the course of this claim. However, as noted above, the evidence affiliated with the claims file does not reflect that this disorder was diagnosed during service, or become manifested to a compensable degree within one year following the veteran's separation from service. As such, hypertension cannot be presumed service connected on a direct basis. 38 C.F.R. §§ 3.307, 3.309. Further, the Board would note that the evidence submitted does not persuasively establish any relationship between a current diagnosis of hypertension and the veteran's service-connected anxiety disorder and associated symptomatology. While the Board notes the June 1998 opinion, as set forth above, in which it appears that the examiner is asserting a relationship between the veteran's anxiety and hypertension and ischemic heart disease, the Board must reject this opinion for several reasons. First, the examiner provides no supporting rationale for his opinion. Second, unlike the other numerous opinions of record, the opinion does not appear to be based on a careful review of the entire evidentiary record. Finally, while the veteran has been extensively worked-up for evidence of organic heart disease, there simply is no competent medical evidence of record that the veteran has any organic heart disease including ischemic heart disease. Thus, the Board must find that service connection for hypertension is not warranted. Similarly, the Board finds that the preponderance of the evidence is against service connection for premature atrial contractions. In this respect, this disorder has consistently been described as not being of organic origin, that is, from an underlying cardiovascular disease. Ultimately, the veteran's complaints of a rapid heartbeat are incorporated in his service-connected anxiety disorder, and have consistently been distinguished from premature atrial contractions. Finally, the Board would note that the veteran did not have any form of underlying cardiovascular disease entity in January 1963, at the time of his hospitalization. As noted above, the resulting report led to the initial grant of service connection. The evidence is not in equipoise and the benefit of the doubt rule is not applicable. 38 C.F.R. § 3.102 (1999). ORDER Service connection for a cardiovascular disorder, claimed as secondary to service-connected anxiety reaction manifested by hyperventilation and cardiac neurosis, is denied. S. L. KENNEDY Member, Board of Veterans' Appeals