Citation Nr: 0004344 Decision Date: 02/18/00 Archive Date: 02/23/00 DOCKET NO. 95-03 175 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUE Entitlement to service connection for the residuals of rheumatic fever, to include a heart disability. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL The veteran and spouse ATTORNEY FOR THE BOARD J. L. Prichard, Counsel INTRODUCTION The veteran had active service from May 1941 to July 1945. This matter comes before the Board of Veterans' Appeals (Board) on appeal of rating decisions of the Muskogee, Oklahoma, regional office (RO) of the Department of Veterans Affairs (VA). This appeal was previously before the Board in March 1997. The issue at that time was whether new and material evidence had been submitted to reopen the veteran's claim for entitlement to service connection for the residuals of rheumatic fever, to include a heart disability. The Board determined that new and material evidence had been submitted to reopen the veteran's claim. The appeal was then remanded to the RO for additional development, and to afford the RO an opportunity to review the veteran's claim on a de novo basis. The requested development has been completed, and the case had been returned to the Board for further appellate review. As the veteran's claim has been reopened, the Board will also review it on a de novo basis. FINDINGS OF FACT 1. The veteran's testimony, statements from other veterans, and daily sick reports indicate that the veteran was treated for rheumatic fever during active service. 2. A heart disability was first diagnosed around 1991, nearly 46 years after the veteran's discharge from service, and include diagnoses of a history of rheumatic fever with aortic, mitral, and tricuspid regurgitation. 3. Medical opinions state that it is unlikely that the veteran's current heart disability is the result of the rheumatic fever for which he was treated during service. CONCLUSION OF LAW The residuals of rheumatic fever, to include a heart disability, were not incurred in or aggravated by active service, nor may it be presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 1991); 38 C.F.R. §§ 3.303, 3.307, 3.309 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION Background The veteran contends that he has developed a heart disability as a result of the rheumatic fever he contracted during active service. The veteran states that he was hospitalized for rheumatic fever in March 1942 and April 1942. He notes that his service medical records are missing and presumed destroyed, but argues that his testimony and the statements he has submitted from other veteran's are sufficient to show that he had rheumatic fever during service. He believes that his current heart disability is the direct result of that illness. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110. If endocarditis or arteriosclerosis becomes manifest to a degree of 10 percent within one year of separation from active service, then it is presumed to have been incurred during active service, even though there is no evidence of these disabilities during service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. A person who submits a claim for benefits under a law administered by the Secretary shall have the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded. 38 U.S.C.A. § 5107. A well grounded claim is a plausible claim, one which is meritorious on its own or capable of substantiation. The claim does not need to be conclusive, but only possible in order to be well grounded. Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). The appellant has the burden of submitting evidence to show that the claim is plausible. Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). In order for there to be a well grounded claim for service connection, there must be evidence of incurrence or aggravation of a disease or injury during service, competent evidence that the veteran currently has the claimed disability, and evidence of a nexus between the inservice disease or injury and the current disability. Caluza v. Brown, 7 Vet. App. 498 (1995); Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992). When an issue involves either medical etiology or medical diagnosis, competent medical evidence is required to make the claim well grounded. Grottveit v. Brown, 5 Vet. App. 91,92 (1993), see also Rucker v. Brown, 10 Vet. App. 67 (1997). The veteran's service medical records are missing, and are presumed to have been destroyed. The VA has a heightened duty to assist the veteran when records are missing and presumed to have been destroyed. Cuevas. v. Principi, 3 Vet. App. 542 (1992). As the veteran's service medical records are unavailable, the VA has attempted to obtain contemporaneous medical evidence from other sources. Daily sick reports from the veteran's unit have been obtained and associated with the claims folder. These records show that the veteran was treated on many occasions in March 1942 and April 1942 for an unspecified illness. The veteran submitted "buddy" statements in support of his contentions in October 1979 and November 1979. These statements were from people who had served with the veteran, and who recalled that he was hospitalized for rheumatic fever in March and April 1942. The veteran was afforded a VA examination in October 1979. He gave a history of hospitalization for rheumatic fever in 1942. However, he was not told and had never been told that he had a heart murmur. On examination, the heart sounds were normal. Afterwards, the impression was acute rheumatic fever by history. Private hospital records from September 1983 show that the veteran was admitted with complaints of chest pain. On examination, the heart sounds were distant, but there were no significant murmurs, gallops, or rubs. An X-ray study of the chest revealed mild tortuosity of the thoracic aorta, but the heart was not enlarged, and the impression was no active disease. A treadmill test was positive because of the elicitation of angina, but demonstrated better than average tolerance for a man the veteran's age. The discharge diagnoses included chest pain secondary to angina pectoris. VA treatment records from December 1990 show that the heart had a regular rate without murmur. May 1991 records are also negative for a murmur, but include an assessment of arteriosclerotic coronary artery disease, symptomatically stable. July 1991 records note a history of rheumatic fever, and an echocardiogram conducted at that time revealed mild to moderate aortic, mitral and tricuspid regurgitation. VA treatment records include the report of echocardiograms conducted in 1992 and 1993. Some abnormal findings were noted, including mild aortic regurgitation, mild mitral regurgitation, and mild tricuspid regurgitation, as well as a dilated left atrium. February 1992 records are negative for a heart murmur. March 1992 records show that the veteran underwent a consultation to determine if valve replacement was required. He was noted to have a history of hypertension and rheumatic fever, with mild aortic insufficiency and tricuspid regurgitation, and moderate mitral regurgitation. The examiner determined that the mitral regurgitation was not impressive, and while the veteran had some significant symptoms, he would not recommend mitral valve replacement at that time. January 1993 records from the cardiology clinic note a history of rheumatic fever during service, and state that the veteran currently has mild mitral regurgitation, with mild aortic insufficiency. VA treatment records from January 1994 show that the veteran had a history of rheumatic fever during service, and state that he would get angina with moderate exertion. The assessment was stable class II angina. October 1994 records show a history of rheumatic fever with aortic and mitral regurgitation. VA treatment records from January 1995 show the history of rheumatic fever in 1942, and note that the veteran currently has mild aortic regurgitation, with thickening of the aortic leaflets. There was also moderate mitral regurgitation and tricuspid regurgitation, as demonstrated by echocardiogram. The diagnostic impressions included coronary artery disease, and history of rheumatic fever, with aortic, mitral and tricuspid regurgitation. The veteran appeared at a personal hearing before a hearing officer in January 1995. He was accompanied by his wife, who also presented testimony. The veteran testified that he had developed rheumatic fever during service, and had been hospitalized for his illness. He states that he had an opportunity to be discharged as a result of this illness, but that he chose to remain with his unit. The veteran said that he was exempt from exercise during service as a result of the rheumatic fever, but that he continued to serve until the end of the war in Europe. The veteran stated that he believed his current heart disability had developed due to the rheumatic fever. He said that his doctor had never told him that his heart disability was the result of rheumatic fever, but had also said that there was no way of knowing with any certainty the cause of the heart disability. The veteran added that he had experienced recurrences of rheumatic fever after discharge from service. See Transcript. February 1995 VA treatment records show that the veteran's history included rheumatic heart disease, with aortic and mitral regurgitation, as well as coronary artery disease. The diagnostic impressions included rheumatic heart disease with aortic and mitral regurgitation. June 1996 VA treatment records include a history of rheumatic fever with aortic and mitral regurgitation. April 1997 VA treatment records show this same history and findings. The veteran underwent a VA examination in May 1997. The claims folder and other medical evidence were reviewed by the examiner in conjunction with the examination. The veteran gave a history of rheumatic fever during active service. He stated that he was diagnosed as having rheumatic fever and a bad valve. More recent records show that aortic, mitral and tricuspid regurgitation had been noted in 1992. The veteran had undergone four vessel coronary bypass surgery in 1995, but was not subjected to valve replacement or valve repair at that time. After the examination and an echocardiogram, the diagnosis was ischemic heart disease status post bypass surgery, mitral regurgitation, and angina pectoris. The examiner stated that the etiology of the mitral regurgitation was uncertain, and added that the echocardiogram did not reveal the classic subvalvular thickening seen in mitral valve disease due to rheumatic heart disease. The possibility of rheumatic fever as the cause of mitral valve regurgitation could not be excluded, but in the opinion of the examiner this disability was more likely than not unrelated to rheumatic heart disease. The other possibilities for the etiology of the valvular lesions include myxomatous mitral valve disease and ischemic etiology. VA treatment records from July 1997 show that the veteran was seen for a follow up visit. The assessments included coronary artery disease and coronary artery bypass graft, as well as a history of rheumatic fever and aortic regurgitation. The veteran underwent an additional VA examination in November 1998. The examiner stated that he reviewed the veteran's claims folder and his medical records in addition to the interview and examination. He noted that the history of rheumatic fever was substantiated by letters from several individuals who were stationed with the veteran. The history of cardiovascular complaints in 1979 and 1983 were noted to have not shown valvular disease. The veteran's 1995 surgery was also discussed. On examination, there was a grade II medium pitched apical holosystolic murmur. It was noted that the veteran had been afforded numerous electrocardiograms which were essentially stable, and which revealed normal sinus rhythm, first degree atrioventricular block, and an inferior myocardial infarction of undetermined age. These had also revealed thickening of the aortic leaflets in August 1992. In summary, the examiner stated that the veteran's major cardiac problem was ischemic heart disease secondary to multiple coronary artery obstructions, which had been managed by four vessel bypass grafting and which appeared to be mildly to moderately symptomatic. This coronary disease was not manifest in or was not otherwise related to the veteran's military service. The examiner added that while the veteran had an apparent history of rheumatic fever while on active duty, there had been no evidence of valvular disease on multiple examinations after separation. The first evidence of valvular disease was an incidental finding on echocardiography in 1992, which was 50 years after his rheumatic fever. The examiner said that while aortic, mitral, and tricuspid insufficiency may result from rheumatic valvulitis, and while these lesions may be asymptomatic for years, it would be very unusual for there to have been no evidence of them such as heart murmurs detected on the veteran's many examinations over the past 50 years. Further, the echocardiographic findings were not those of rheumatic valvular disease. The examiner opined that it was extremely unlikely that the veteran's present valvular disease, which is hemodynamically insignificant and clinically silent, is related to the rheumatic fever in service. Other etiologies for the valvular disease were more likely, including myxomatous degeneration of the valves, or coronary disease. These were also noted to have first become evident many years after discharge from service, and there was no evidence that these conditions existed during service. Analysis Initially, the Board finds that the veteran has submitted evidence of a well grounded claim. The March 1997 remand noted that the January 1995 diagnosis of a history of rheumatic fever with aortic, mitral, and tricuspid regurgitation created a plausible basis upon which the veteran's claim could be granted. Furthermore, it appears that the duty to assist the veteran in the development of his claim has been completed, and the Board is unaware of any additional relevant evidence that might be obtained that would assist in reaching a decision in this case. Therefore, the Board will proceed with consideration of the veteran's claim on the merits. After careful consideration of the veteran's contentions, the medical evidence, and the other evidence of record, the Board finds that entitlement to service connection for the residuals of rheumatic fever, to include a heart disability, is not merited. The veteran's service medical records are not available, but he has testified that he developed rheumatic fever during service, and his testimony is supported by the statements he has submitted from other veterans, as well as the daily sick reports from his unit. At this juncture, the Board would like to stress to the veteran that all the available evidence supports his contention that he developed rheumatic fever in service, and that there is absolutely no reason to doubt his veracity. The problem with the veterans' claim is that the evidence does not indicate that his current heart disability is the result of the rheumatic fever sustained during service. The Board recognizes the veteran's sincere belief that he has heart disease as a result of the rheumatic fever he developed during service. However, the veteran is not a physician, and he is not qualified to express a medical opinion as to such a relationship. Espiritu v. Derwinski, 2 Vet. App. 492, 495 (1992). The VA treatment records from January and February 1995 include the history of rheumatic fever, as well as the current findings of mitral, aortic, and tricuspid regurgitation, and the February 1995 records even include a diagnosis of rheumatic heart disease. However, while these findings are suggestive of a possible relationship between the rheumatic fever in service and the current heart disability, there is no indication that the examiners who reached these conclusions had the veteran's medical history available for study. Furthermore, these examiners were not primarily concerned with the etiology of the heart disability. The veteran was afforded VA examinations in May 1997 and November 1998 that were in part designed to determine the etiology of his heart disease. His claims folder was available for review, and his medical history was studied by both of these examiners. Both of the examiners operated under the assumption that the veteran had been treated for rheumatic fever in service, but concluded that his current heart disability was most likely not related to that illness. The May 1997 examiner stated that the echocardiogram findings were not consistent with mitral valve disease due to rheumatic heart disease, and opined that the veteran's heart disability was more likely than not unrelated to rheumatic heart disease. The November 1998 examiner was more emphatic, and opined that it was extremely unlikely that the veteran's present valvular disease was related to the rheumatic fever in service. Both of these examiners offered alternative etiologies that were more likely explanations for the development of the veteran's valvular disease, including his coronary artery disease. However, they also added that the other possible etiologies were also unrelated to active service. The Board finds that these two opinions outweigh the findings contained in the January 1995 and February 1995 VA records. Therefore, as the evidence does not show the development of any heart disability either during service or until many years after discharge from service, as the evidence indicates that it is more likely than not that his heart disease is not the result of the rheumatic fever treated in service, and as no other residuals of rheumatic fever have been identified, entitlement to service connection is not warranted. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 1991); 38 C.F.R. §§ 3.303, 3.307, 3.309. ORDER Entitlement to service connection for the residuals of rheumatic fever, to include a heart disability, is denied. WAYNE M. BRAEUER Member, Board of Veterans' Appeals