Citation Nr: 0002747 Decision Date: 02/03/00 Archive Date: 02/10/00 DOCKET NO. 98-06 980A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUE Entitlement to service connection for heart disease to include congestive heart failure, coronary artery disease, and ischemia. REPRESENTATION Appellant represented by: Missouri Veterans Commission WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Wm. Kenan Torrans, Associate Counsel INTRODUCTION The veteran served on active duty from August 1963 to March 1985. This matter arises from rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri, which denied the benefit sought. The veteran filed a timely appeal, and the case has been referred to the Board of Veterans' Appeals (Board) for resolution. FINDING OF FACT There is no competent medical evidence of a nexus or link between any currently diagnosed heart disease and the veteran's active service. CONCLUSION OF LAW The veteran's claim for service connection for heart disease to include congestive heart failure, coronary artery disease, and ischemia is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). REASONS AND BASES FOR FINDING AND CONCLUSION The law provides that service connection may be granted for a disability resulting from a disease or injury that was incurred in or aggravated by service. See 38 U.S.C.A. §§ 1110, 1131 (West 1991); 38 C.F.R. § 3.303 (1999). If a condition noted during service is not shown to be chronic, then continuity of symptomatology after service is generally required for service connection. See 38 C.F.R. § 3.303(b) (1999). Where a veteran served for 90 days or more during a period of war and a chronic disease, to include cardiovascular disease, became manifest to a degree of 10 percent within one year from the date of termination of such service, the chronic disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 1991); 38 C.F.R. §§ 3.307, 3.309 (1999). The threshold question which must be answered is whether the veteran has presented a well-grounded claim for service connection. The veteran has the "burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded." See 38 U.S.C.A. § 5107(a) (West 1991); Robinette v. Brown, 8 Vet. App. 69, 73 (1995). A well-grounded claim is "a plausible claim, one which is meritorious on its own or capable of substantiation. Such a claim need not be conclusive, but only possible to satisfy the initial burden of § [5107]." Murphy v. Derwinski, 1 Vet. App. 78, 81 (1995). To establish that a claim for service connection is well grounded, the claimant must satisfy three elements. First, there must be evidence of an incurrence or aggravation of an injury or disease in service. Second, there must be competent (i.e. medical) evidence of a current disability. Third, there must be evidence of a nexus or link between the in-service injury or disease and the current disability, as shown through the medical evidence. See Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997). Lay or medical evidence, as appropriate, may be used to substantiate service incurrence. See Caluza v. Brown, 6 Vet. App. 489, 507 (1995); Layno v. Brown, 6 Vet. App. 465, 469 (1994). Alternatively, a claim may be well grounded based on the application of the rule for chronicity and continuity of symptomatology, set forth in 38 C.F.R. § 3.303(b). See Savage v. Gober, 10 Vet. App. 488, 495-97 (1997). The veteran contends that he began to experience chest pains in service, in approximately September or October 1984, and that he had been diagnosed with angina at that time. He maintains that his currently diagnosed heart disease, including coronary artery disease, congestive heart failure, and ischemia had their onset during his active service. Therefore, he asserts that service connection for his heart disorders is warranted. The veteran's service medical records show that in September and October 1984, he was seen for complaints of chest pain of an unknown etiology. His chest pains persisted, and in early January 1985, a treatment note shows that he experienced what appeared to be angina-like symptoms, and was referred for a stress test. Later in January 1985, the veteran underwent a thallium stress test and cardiac catheterization to evaluate the nature of his chest pains. The records show that the veteran reported that he had "probable angina," and angina was listed as an initial provisional diagnosis. However, the thallium treadmill test conducted later in January 1985 failed to reveal cardiac symptomatology or indications of angina. The veteran's blood pressure was noted to be 140/100, and later 140/84, and his cardiovascular examination showed a regular heart rate, regular rhythm, and no murmurs or gallops. No evidence of abnormalities was shown. The cardiac catheterization showed the veteran to have normal coronary arteries, and also did not disclose any coronary artery disease or related heart problems. The diagnosis rendered pursuant to the cardiac catheterization was non- cardiac chest pain, normal coronary arteries. Post-service medical treatment records show that the veteran experienced a myocardial infarction and was diagnosed with coronary artery disease in May 1989. He continued to suffer from heart problems from May 1989 to the present, and has since been diagnosed with congestive heart failure and ischemia. Treatment records dated in May 1989 note that the veteran had been seen in 1985 for complaints of a "different" type of chest pain, and that he did not have a history of high blood pressure. Treatment records dated in June 1989 also contain the attending physician's notes that the veteran had undergone a cardiac catheterization in January 1985 in service for "a different type of chest pain," and that he had no coronary-related diagnoses. Subsequent treatment records dated in February 1990 state that the veteran's cardiac history dated back "only" to May 1989 when he experienced a myocardial infarction, and note that he had also been diagnosed with unstable angina at that time. In addition, a treatment record dated in October 1994 shows that the veteran was diagnosed with coronary artery disease, congestive heart failure, ischemic disease, and other diseases related to the heart. The attending physician also noted that the veteran was first diagnosed with coronary artery disease in 1989 after experiencing a non-Q-wave myocardial infarction. None of the post-service treatment records contain any medical opinion that the veteran's currently diagnosed heart disorders were incurred in service. In fact, the records appear to distinguish the chest pains the veteran experienced in service in 1985 from the chest pains and symptoms associated with the onset of the myocardial infarction of 1989. Remaining clinical treatment records dating through June 1999 show that the veteran continued to receive treatment for heart disease, but do not contain any opinion suggesting that the heart disease was incurred in service. In March 1997, the veteran underwent a VA rating examination. He reported a history of having experienced chest pain in service, and that he had been diagnosed with angina at that time. The examiner noted that he had experienced a myocardial infarction in 1989, and that he currently suffered from heart disease. However, the examiner failed to include any opinion as to the etiology of the veteran's heart disease, other than noting the veteran's self-reported history. In October 1998, the veteran appeared at a personal hearing before a Hearing Officer at the RO in which he testified that he had experienced chest pain and had been diagnosed with angina in service. He testified that he had first experienced heart-related symptoms in October 1984 which included shortness of breath and chest pain. He testified that he was transferred from Nellis Air Force Base in Nevada to the military hospital at Ford Ord, California, and later to Letterman U.S. Army Hospital (USAH), for his symptoms to be evaluated in January 1985. He stated that he underwent a cardiac catheterization which showed normal results. According to the veteran, he sought treatment for his chest pain symptoms in 1985 shortly after his discharge, and was prescribed nitroglycerine to relieve those chest pains. The veteran stated that he experienced his first myocardial infarction in 1989, and that since that time, he had experienced a stroke and an additional myocardial infarction. Through his service representative, the veteran offered his opinion that his service medical records were "woefully inadequate" in that they did not adequately cover his last continuous periods of service. He stated that upon complaining of chest pain in October 1984, the treating military physician advised him that he was 95 percent certain that the veteran had angina, but that the physician was unsure. Accordingly, the veteran indicated, more tests were ordered including catheterization and a treadmill test. In further support of his claim, the veteran submitted eight pages of computer generated treatises relating to heart disease. That material covered topics including warning signs for angina pectoris, treatment, and related subjects such as ischemic heart disease. The Board has evaluated the above-discussed evidence, and must conclude that the veteran has not submitted evidence of a well-grounded claim for service connection for heart disease to include congestive heart failure, coronary artery disease, and ischemia. Initially, the Board observes that the veteran's service medical records, which are extensive, do not currently appear to be incomplete, and in fact, additional records were obtained after the veteran's personal hearing. The relevant period, dating from September 1984 through January 1985, is well documented by treatment records which essentially support the veteran's statements and testimony that he was seen for complaints of chest pain at that time. In addition, the reports of the treadmill test and cardiac catheterization conducted in 1985 have been obtained and associated with the claims file. The Board acknowledges that the veteran was given a provisional diagnosis of angina following his complaints of chest pain in September and October 1985. However, contrary to his assertions, the final diagnosis, after extensive testing was not angina, and, as noted above, the thallium treadmill test and cardiac catheterization failed to show that he had any cardiac irregularities or abnormalities. In fact, the test results included diagnoses of normal coronary arteries. Further, the veteran's post-service medical treatment records show the first diagnosis of coronary artery disease to have been rendered in May 1989, some four years after the veteran's discharge from service. The subsequent treatment records specifically note that coronary artery disease was first diagnosed in 1989 when the veteran experienced his first myocardial infarction. The Board further acknowledges that the veteran current diagnoses of heart disease to include coronary artery disease, congestive heart failure, and ischemia, but also notes that the record fails to contain any medical opinion suggesting that these diseases were incurred in service. The contemporaneous clinical treatment records only show the existence of a present disability, but do not contain any nexus opinion. As to the symptoms including chest pain the veteran experienced in service, his post-service treating physicians have distinguished the chest pain experienced in 1985 from the symptoms associated with his coronary artery disease and myocardial infarctions. Moreover, while the veteran clearly believes that his heart disease is related to service and the chest pains he experienced in 1984, the veteran, as a lay person, is not competent to address an issue requiring an expert medical opinion, to include medical diagnoses or opinions as to medical etiology. See Moray v. Brown, 5 Vet. App. 211, 214 (1995); Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992). The issue of whether the veteran suffered from heart disease during service and whether his current symptomatology is related to his period of military service involves a medical diagnosis or opinion as to medical causation; thus competent medical evidence is required. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). The record does not reflect that the veteran has a medical degree or qualified medical experience. See Espiritu, supra. Thus, although he is competent to testify as to observable symptoms, such as pain, he is not competent to provide evidence or opinion that the observable symptoms are manifestations of diagnosed disability. See Savage, 10 Vet. App. at 497. The Board further acknowledges that the veteran has submitted medical treatise evidence in support of his claim. However, "[g]enerally an attempt to establish a medical nexus to a disease or injury solely by generic information in a medical journal or treatise 'is too general and inconclusive' to well ground the claim." Sacks v. West, 11 Vet. App. 314, 317 (1998) (citing Beausoliel v. Brown, 8 Vet. App. 459, 463 (1996)); see also Libertine v. Brown, 9 Vet. App. 521, 523 (1996) (holding that medical treatise evidence proffered by the appellant in connection with his lay testimony was insufficient to satisfy requirements of medical evidence of a nexus to well ground the claim.). "Medical treatise evidence, however, can provide important support when combined with an opinion by a medical professional." Mattern v. West, 12 Vet. App. 222, 228 (1999). However, in the absence of a medical opinion establishing the required nexus between the veteran's active service and his currently diagnosed heart disease, his claim must be denied as not well grounded. For the above reasons, it is the opinion of the Board that the veteran has failed to meet his initial burden of submitting evidence of a well-grounded claim for service connection for heart disease to include coronary artery disease, congestive heart failure, and ischemia. The Board has not been made aware of any additional relevant evidence which is available which could serve to well ground the veteran's claim. As the duty to assist is not triggered here by a well-grounded claim, the Board finds that the VA has no duty to further develop the veteran's claim. See 38 U.S.C.A. § 5103 (West 1991); McKnight v. Gober, 131 F.3d 1483 (Fed. Cir. 1997); Epps, supra; Grivois v. Brown, 6 Vet. App. 136 (1994). The Board also views its discussion as sufficient to inform the veteran of the evidence necessary to complete a well-grounded claim for service connection for heart disease to include coronary artery disease, congestive heart failure, and ischemia. See Robinette, supra. The Board recognizes that this matter is being disposed of in a manner that differs from that employed by the RO. The RO denied the veteran's claim on the merits while the Board has found his claim to be not well grounded. However, when an RO does not specifically address the question whether a claim is well grounded, but rather, as here, proceeds to adjudication on the merits, there is no prejudice to the veteran solely from the omission of the well-grounded analysis. See Meyer v. Brown, 9 Vet. App. 425, 432 (1996). ORDER Evidence of a well-grounded claim not having been submitted, service connection for heart disease to include congestive heart failure, coronary artery disease, and ischemia is denied. S. L. KENNEDY Member, Board of Veterans' Appeals