Citation Nr: 0000637 Decision Date: 01/10/00 Archive Date: 01/19/00 DOCKET NO. 95-17 975 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE Entitlement to service connection for a chronic cardiovascular disorder. REPRESENTATION Appellant represented by: AMVETS WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Michelle L. Nelsen, Associate Counsel INTRODUCTION The veteran had active duty from August 1986 to January 1988. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 1994 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. FINDINGS OF FACT 1. The RO has obtained all relevant evidence necessary for the equitable disposition of the veteran's appeal. 2. The medical evidence of record fails to reveal any chronic, organic cardiovascular disorder resulting from the in-service automobile accident or any other incident of service. CONCLUSION OF LAW No chronic cardiovascular disorder was incurred during active duty service. 38 U.S.C.A. §§ 1131, 5107 (West 1991); 38 C.F.R. §§ 3.102, 3.303 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION As a preliminary matter, the Board finds that the veteran's claim is well grounded. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.102 (1999). See Murphy v. Derwinski, 1 Vet. App. 78, 91 (1990); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). That is, the Board finds that the veteran has presented a claim which is not implausible when his contentions and the evidence of record are viewed in the light most favorable to the claim. The Board is also satisfied that all relevant facts have been properly and sufficiently developed to address the issue at hand. Factual Background The veteran's July 1986 enlistment physical examination was negative for any cardiac abnormalities. In February 1987, the veteran was involved in an automobile accident. He was initially treated at a private hospital for multiple injuries, including a right pneumothorax. Emergency notes indicated that he also incurred a seatbelt strap contusion. The veteran was discharged in March 1987 and immediately transferred to a military hospital. Examination at admission revealed normal sinus rhythm with murmur. No cardiac symptoms were reported or treated. In April 1987, the veteran was transferred to Wright Patterson Air Force Base (WPAFB). The June 1987 Medical Evaluation Board report showed that examination in April 1987 revealed regular heart rate and rhythm with a grade I systolic ejection murmur. This report, as well as the August 1987 and December 1987 addenda, was negative for any cardiac symptoms or treatment. In January 1988, the veteran was discharged from active duty and placed on the temporary disability retired list for physical disability. In May 1988, the veteran was afforded a VA general medical examination for purposes of unrelated claims. He indicated that he was told he had a systolic murmur since the accident. Examination revealed a faint apical systolic murmur in the left fourth intercostal space. Pulse was 72 and regular. No cardiac diagnosis was offered. Records from WPAFB showed that in August 1988, the veteran presented with a history of increased blood pressure and possible arrhythmia. Examination revealed sinus arrhythmia. An electrocardiogram (EKG) performed at that time was normal. March 1989 records indicated that heart rate and rhythm were regular and without murmur. An EKG performed in July 1993 was normal. Notes dated in August 1993 indicated that the veteran related a history of palpitations for several years at rest or with exertion. Examination revealed regular heart rate and rhythm with no murmur. An EKG was normal. Holter monitor results were negative. Telemetry suggested atrial tachycardia. The impression was paroxysmal symptomatic atrial tachycardia. Possible causes included hypertension, valvular heart disease, coronary artery disease, or hyperthyroidism. In October 1993, the veteran submitted an informal claim for service connection for cardiac arrhythmia. He indicated that he first sought treatment for this disorder in July 1988. Although he continued to have problems, he did not seek treatment again until July 1993, when the disorder worsened. He was now taking medication. The veteran also stated that, although he was diagnosed as having a heart murmur in 1987 in service, he currently had no murmur. A July 1994 report from Randall C. Orem, D.O., indicated that the veteran sought an opinion concerning his palpitations. The veteran related that he had no palpitations until after his car accident. The palpitations were paroxysmal in onset and occasionally accompanied by chest discomfort. They had been controlled with medication. Dr. Orem stated that a review of the emergency room chart from the veteran's accident revealed a notation of a contusion mark on the anterior chest and a right pneumothorax that required a thoracostomy tube. The next year, the veteran began having the sensation of palpitations, though none were confirmed during medical visits. He had been diagnosed as having paroxysmal atrial tachycardia. Dr. Orem noted that an echocardiogram performed in August 1993 showed no evidence of valvular pathology, chamber dilatation, or congenital anomaly. He also noted the veteran's brief history of a systolic murmur. An August 1993 graded exercise treadmill test revealed no pathology or subjective chest pain. Examination revealed regular heart rate and rhythm with a brief systolic apical murmur. No other abnormalities were appreciated. Dr. Orem concluded that it seemed "entirely possible that in light of the substantial deceleration in chest injury of significant enough force to cause a pneumothorax, a contusion of the anterior myocardium against the posterior portion of the sternum may have resulted, and in the healing process, has caused an area of electrical instability or decremental conduction." He conceded that there was no way to prove this opinion, but noted that the veteran's history of sensation of palpitations after the accident had been well documented. Dr. Orem advised the veteran to have a physician exclude other possible causes of atrial ectopic activity, such as thyroid level, electrolytes, magnesium and sed rate. However, he added that, considering his age group and the lack of other symptoms, those possibilities would likely be of low diagnostic yield. The veteran testified at a personal hearing in August 1995. He first sought treatment for a heart problem in August 1988 at WPAFB. He next sought medical treatment for a heart problem in August 1993. In between those times, the veteran continued to have palpitations of varying intensity on a daily basis. He took verapamil and Atenolol, which mostly controlled his symptoms. The veteran underwent a VA cardiology examination in March 1996. He reported a history of being in an auto accident and paroxysmal palpitations since that time. The episodes were sometimes associated with shortness of breath. The examiner commented on previous objective findings, including a normal EKG performed in September 1995. Examination initially revealed a regular heart rate. However, during the examination, he experienced an episode of palpitations with increased heart rate. Rhythm was regular. No murmur was found. The diagnosis was paroxysmal palpitations with a history of systolic murmur. An echocardiogram performed in April 1996 showed normal overall left ventricular systolic function and no evidence of valvular disease. The 24-hour holter monitor report from April 1996 indicated that basic rhythm was sinus. The maximum heartbeats per minute was 142 and the minimum was 48. There was one short run of junctional tachycardia without symptoms. There were no supraventricular tachycardias. In an April 1996 addendum, the VA examiner indicated that, after a review of the additional tests, there was no objective evidence of organic heart disease. Additional records from WPAFB dated in January 1994, November 1994, December 1995, and January 1998 indicated that the veteran continued to complain of palpitations, although it was noted that all diagnostic tests had been normal. His treatment consisted of medications only. In January 1999, the RO received the veteran's records from the Social Security Administration (SSA). The disability determination of April 1998 indicated that the veteran was found disabled as of August 1997 due to orthopedic disorders. The accompanying medical records generally consisted of record from WPAFB and VA facilities. The disability evaluations specifically performed for purposes of the SSA determination did not include evaluation of any cardiac disorder. Analysis Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). Service connection may be demonstrated either by showing direct service incurrence or aggravation or by using applicable presumptions, if available. Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994) (specifically addressing claims based ionizing radiation exposure). Service connection requires a finding that there is a current disability that has a definite relationship with an injury or disease or some other manifestation of the disability during service. Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992); Cuevas v. Principi, 3 Vet. App. 542, 548 (1992). A disorder may be service connected if the evidence of record, regardless of its date, shows that the veteran had a chronic disorder in service or during an applicable presumptive period, and that the veteran still has such a disorder. 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488, 494-95 (1997). Such evidence must be medical unless it relates to a disorder that may be competently demonstrated by lay observation. Savage, 10 Vet. App. at 495. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." 38 C.F.R. § 3.303(b). If the disorder is not chronic, it may still be service connected if the disorder is observed in service or an applicable presumptive period, continuity of symptomatology is demonstrated thereafter, and competent evidence relates the present disorder to that symptomatology. Id. at 496-97. Again, whether medical evidence or lay evidence is sufficient to relate the current disorder to the in-service symptomatology depends on the nature of the disorder in question. Id. Disorders diagnosed after discharge may still be service connected if all the evidence, including pertinent service records, establish that the disorder was incurred in-service. 38 U.S.C.A. § 1113(b); 38 C.F.R. § 3.303(d). Some chronic diseases are presumed to have been incurred in service, although not otherwise established as such, if manifested to a degree of ten percent or more within one year of the date of separation from service. 38 U.S.C.A. § 1112(a)(1); 38 C.F.R. § 3.307(a)(3); see 38 U.S.C.A. § 1101(3) and 38 C.F.R. § 3.309(a) (listing applicable chronic diseases, including arteriosclerosis and endocarditis, to include all forms of valvular heart disease). During the pendency of the veteran's appeal, VA promulgated new regulations concerning the evaluation of cardiovascular disorders, effective January 12, 1998. See 62 Fed. Reg. 65,207 (codified at 38 C.F.R. pt. 4). Generally, where the law or regulation changes after a claim has been filed or reopened but before the administrative or judicial appeal process has been concluded, the version most favorable to the veteran will apply. Karnas v. Derwinski, 1 Vet. App. 308, 313 (1991). The Board notes that the RO appears to have addressed the amendments in its August 1998 supplemental statement of the case. However, the RO did not discuss the fact that the amendments deleted 38 C.F.R. §§ 4.100, which provided that tachycardia and bradycardia, as well as the various arrhythmias, did not represent generally acceptable cardiovascular diagnoses. Inasmuch as the previous version of the regulation may have prevented the establishment of service connection for certain cardiovascular disorders, the Board finds that the amended regulations are more favorable to the veteran. Accordingly, those regulations will be considered, to the extent applicable, in the veteran's service connection claim. Moreover, the Board finds that such consideration will not result in any prejudice to the veteran. Bernard v. Brown, 4 Vet. App. 384, 392-94 (1993). Initially, the Board notes that there is no current diagnosis of a specified chronic disability for purposes of presuming the in-service incurrence of a cardiac disorder. 38 U.S.C.A. § 1112(a)(1); 38 C.F.R. § 3.307(a)(3). The veteran is currently diagnosed as having paroxysmal atrial tachycardia from August 1993. However, a review of the medical evidence reveals no objective evidence of any organic cardiovascular disorder. For example, even though the veteran experienced palpitations during the March 1996 VA examination, the examiner found no evidence of organic heart disease after reviewing results of an EKG, echocardiogram, and holter monitor testing. Similarly, all previous testing, including the August 1993 graded exercise treadmill test, revealed no pathology. As service connection may only be established for current disability resulting from a disease or injury incurred or aggravated in service, the absence of objective medical evidence of cardiac disease following the in-service automobile accident is fatal to the veteran's current claim. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). In his July 1994 report, Dr. Orem opined that it was possible that the veteran's diagnosis was related to the in-service automobile accident. However, he conceded that there was no way to prove his opinion. Moreover, his own review of the medical evidence found no objective evidence of cardiac disorder. The Board finds that Dr. Orem's opinion as to the possibility of a relationship between the auto accident and paroxysmal atrial tachycardia is insufficient to outweigh the lack of evidence of organic heart disorder. In his correspondence, the veteran emphasizes that medical evidence shows the presence of a systolic murmur. On this point, the Board observes that a heart murmur can be, but is not always, indicative of underlying organic cardiac disease. In this case, a review of the medical evidence finds that on several occasions no murmur was found at all. During the times when a murmur was heard, there again was no clinical evidence supporting a finding of cardiac pathology. Accordingly, the Board finds that the preponderance of the evidence is against entitlement to service connection for a chronic, organic cardiovascular disorder. 38 U.S.C.A. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303. ORDER Entitlement to service connection for a chronic cardiovascular disorder is denied. BRUCE KANNEE Member, Board of Veterans' Appeals