CARDIOMYOPATHY

Summary

The Veteran, an Army Veteran who served from October 1988 to November 1991, appeals the denial of service connection for congestive heart failure (CHF) with atrial fibrillation and an automatic implantable cardioverter-defibrillator (AICD), and for hypertension. The Veteran claimed these conditions were either directly caused by service or secondary to service-connected obstructive sleep apnea (OSA) and/or a right ankle disability. Service treatment records showed no heart issues during service, though the Veteran did report chest pain and shortness of breath attributed to other causes. A private clinician, Dr. Levin, opined that CHF and hypertension were likely secondary to OSA, but failed to consider that the heart diagnoses predated the OSA diagnosis. A March 2025 VA examiner found the heart conditions were at least as likely as not aggravated by OSA but could not establish a baseline severity. For hypertension, the same examiner found it at least as likely as not aggravated by OSA. However, a May 2025 VA examiner opined that both the heart conditions and hypertension were less likely than not incurred in or caused by service, citing a lack of substantiating evidence and a more likely post-service etiology. The Board found the May 2025 VA examiner's opinions significantly probative. For CHF, the Board denied service connection, finding that without a baseline severity, the aggravation by OSA could not be established. For hypertension, the Board denied service connection, noting it predated OSA and that Dr. Levin's opinion was not probative. The Board also found the May 2025 VA examiner's opinion regarding hypertension, which found it less likely than not related to the right ankle disability, to be significantly probative. The Board denied both claims.

Rationale

No in-service onset or treatment for CHF/atrial fibrillation/AICD; Private opinion lacked probative value due to timeline discrepancy; March 2025 VA examiner could not establish baseline severity for aggravation claim; May 2025 VA examiner found less likely than not related to service

Full Decision Text

Citation Nr: A26038392
Decision Date: 04/23/26	Archive Date: 04/23/26

DOCKET NO. 250519-546084
DATE: April 23, 2026

ORDER

Entitlement to service connection for congestive heart failure (CHF) with atrial fibrillation with automatic implantable cardioverter-defibrillator (AICD) is denied. 

Entitlement to service connection for hypertension (high blood pressure) is denied.

FINDINGS OF FACT

1. The Veteran's congestive heart failure with atrial fibrillation with AICD did not have its onset during active-duty service, is not otherwise related to active-duty service, and was not caused or shown by a medically established baseline that it was aggravated by service-connected obstructive sleep apnea (OSA).

2. The Veteran's hypertension (high blood pressure) did not have its onset during active-duty service or within one year of separation from service, is not otherwise related to active-duty service, and was not caused or shown by a medically established baseline that it was aggravated by service-connected OSA or a right ankle disability.

CONCLUSIONS OF LAW

1. The criteria for service connection for congestive heart failure with atrial fibrillation with AICD have not been met. 38 U.S.C. §§ 1110, 5107 (2024); 38 C.F.R. §§ 3.102, 3.310 (2025).

2. The criteria for service connection for hypertension (high blood pressure) have not been met. 38 U.S.C. §§ 1110, 5107 (2024); 38 C.F.R. §§ 3.303, 3.310 (2025).

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active-duty in the Army from October 1988 to November 1991. 

These matters come to the Board of Veterans' Appeals (Board) on appeal from a May 2025 rating decision.

In May 2025, the Veteran submitted a VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement) and elected the Evidence Submission docket. Therefore, the Board may only consider the evidence of record at the time of the May 2025 agency of original jurisdiction (AOJ) decision, as well as any evidence submitted by the Veteran within 90 days following the receipt of the VA Form 10182. 38 C.F.R. § 20.302(a). 

If the Veteran would like VA to consider any evidence that was submitted and the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claims, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

Service Connection - CHF with Atrial Fibrillation with AICD

The Veteran claimed that his CHF with atrial fibrillation with AICD was either caused directly by service or secondary to obstructive sleep apnea (OSA). 

A review of the Veteran's service treatment reports (STRs) revealed a normal clinical evaluation of the heart at the Veteran's entrance examination in July 1988. The Veteran reported chest pain in April 1991 which was reported to be likely muscular. In August 1991, the Veteran reported shortness of breath which was attributed to obesity and exercise intolerance. In September 1991, the Veteran reported chest pain diagnosed as chest wall pain. The Veteran was not treated for congestive heart failure or atrial fibrillation during service. 

A sleep study dated in January 2021 reveals a diagnosis of OSA. 

Associated with the claims file is a medical evaluation performed remotely by M. Levin, M.D., in October 2024. Dr. Levin reviewed the claims file, noted a diagnosis of congestive heart failure with atrial fibrillation and pacemaker and concluded that it was more likely than not secondary to service-connected OSA. The examiner's rationale was that OSA has been associated with many different forms of cardiovascular disease including hypertension, stroke, heart failure, and coronary artery disease. According to the American Heart Association, OSA is an independent risk factor for atrial fibrillation in patients without other underlying cardiac disorders. Moreover, OSA independently increases the risk of coronary events. The clinician indicated that repetitive hypoxemia and reoxygenation elicited by OSA may result in oxidative stress and systemic inflammation, which contribute to coronary atherosclerosis and acute myocardial infarction (MI) events and is a risk factor for atrial fibrillation in
 atrial fibrillation and pacemaker and concluded that it was more likely than not secondary to service-connected OSA. The examiner's rationale was that OSA has been associated with many different forms of cardiovascular disease including hypertension, stroke, heart failure, and coronary artery disease. According to the American Heart Association, OSA is an independent risk factor for atrial fibrillation in patients without other underlying cardiac disorders. Moreover, OSA independently increases the risk of coronary events. The clinician indicated that repetitive hypoxemia and reoxygenation elicited by OSA may result in oxidative stress and systemic inflammation, which contribute to coronary atherosclerosis and acute myocardial infarction (MI) events and is a risk factor for atrial fibrillation in patients without other underlying cardiac disorders. 

At a March 2025 VA heart examination, the Veteran reported the onset of atrial fibrillation in 2003-2005 and congestive heart failure in 2007 with AICD placement. The examiner diagnosed the Veteran with congestive heart failure, AICD, and atrial fibrillation. The examiner indicated that she was unable to determine a baseline level of severity of the heart conditions based upon medical evidence available prior to aggravation or the earliest medical evidence following aggravation by OSA. The examiner nonetheless opined that the Veteran's heart conditions were at least as likely as not aggravated beyond their natural progression by OSA. The examiner's rationale was that literature shows OSA can worsen heart failure in several ways including increased sympathetic nervous system activation with resultant increased heart rate, blood vessel constriction, increased blood pressure and increased heart strain, intermittent hypoxia and reoxygenation with increased oxidative stress and inflammation, fluid retention with increased heart workload and sleep fragmentation which is known to increase inflammation. All of these consequences of OSA worsen heart failure. Atrial fibrillation with AICD can be worsened in the same way through increased work on the heart due to hypoxia and sympathetic nervous system activation. 

In May 2025, a VA examiner opined that the Veteran's heart conditions were less likely than not incurred in or caused by service. The examiner's rationale was that there is a lack of substantiating evidence supporting a nexus between the current diagnosis of atrial fibrillation, AICD and military service. Without chronicity during service or after service, a post-service event, illness, or injury is considered to be a more likely etiology.  

The Board finds that entitlement to service connection for CHF with atrial fibrillation with AICD is not warranted.

As an initial matter, while the March 2025 VA examiner opined that the Veteran's CHF with atrial fibrillation with AICD was at least as likely as not aggravated by OSA, the Board finds that without establishing a baseline severity, the Veteran's CHF with atrial fibrillation with AICD is not aggravated by the Veteran's service-connected OSA. The Veteran has not offered competent and probative medical evidence in support of his service claim based on aggravation.  

With regard to whether the Veteran's CHF with atrial fibrillation with AICD was caused by service-connected OSA, while the private clinician Dr. Levin provided a detailed rationale for his opinion which found that CHF with atrial fibrillation with AICD was secondary to (caused by) service-connected OSA, Dr. Levin failed to consider that the heart diagnoses pre-dated the diagnosis of OSA by many years. Specifically, the Veteran was diagnosed with atrial fibrillation in 2003-2005 and CHF in 2007 and OSA was not diagnosed until 2021. Therefore, the private opinion from Dr. Levin is of no probative value. 

The May 2025 VA examiner's opinion weighs against the claim. As noted above, the examiner indicated that it was less likely than not that the Veteran's CHF with atrial fibrillation with AICD was incurred in or caused by service. The examiner considered and addressed the relevant evidence of record, the Veteran's contentions, and provided rationale for the opinion. For those reasons, the Board finds the VA examiner's opinion significantly probative. Barr v. Nicholson, 21 Vet. App. 303 (2007); Stefl v. Nicholson, 21 Vet. App. 120 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008).

The Board has also considered the lay evidence of record. The Veteran is competent to describe what he has personally observed or experienced. However, the ultimate questions of diagnoses and etiology in this case extend beyond an immediately observable cause-and-effect relationship and are beyond the competence of lay witnesses. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson,
 the VA examiner's opinion significantly probative. Barr v. Nicholson, 21 Vet. App. 303 (2007); Stefl v. Nicholson, 21 Vet. App. 120 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008).

The Board has also considered the lay evidence of record. The Veteran is competent to describe what he has personally observed or experienced. However, the ultimate questions of diagnoses and etiology in this case extend beyond an immediately observable cause-and-effect relationship and are beyond the competence of lay witnesses. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Therefore, the Veteran is not competent to provide an etiology opinion in this case.

Accordingly, the Board finds that the benefit-of-the-doubt rule is not applicable as the evidence is not in approximate balance, and entitlement to service connection for CHF with atrial fibrillation with AICD is not warranted. 38 U.S.C. § 5107(b); Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc)

Service Connection - Hypertension

The Veteran claimed that his hypertension was either caused directly by service or secondary to OSA and/or a right ankle disability. 

A review of the Veteran's STRs revealed a normal clinical evaluation of the heart at the Veteran's entrance examination in July 1988. The Veteran's blood pressure was recorded as 126/80. The Veteran was not treated for hypertension during service. 

As noted above, a sleep study dated in January 2021 reveals a diagnosis of OSA. 

In the October 2024 private medical evaluation, Dr. Levin indicated that the Veteran has a diagnosis of hypertension and opined that it was more likely than not secondary to OSA and chronic pain. The examiner's rationale was that scientific literature supports a connection between OSA and hypertension and according to the American Heart Association, the seventh report of the Joint National Committee identified OSA as an important identifiable cause of hypertension.

At a March 2025 VA hypertension examination, the Veteran reported that he was diagnosed with hypertension in the 1990s. The examiner diagnosed the Veteran with hypertension and indicated that she was unable to determine a baseline level of severity of the hypertension based upon medical evidence available prior to aggravation or the earliest medical evidence following aggravation by OSA. The examiner nonetheless opined that the Veteran's hypertension was at least as likely as not aggravated beyond its natural progression by OSA. The examiner's rationale was that in OSA, the airway repeatedly becomes blocked during sleep, causing episodes of breathing cessation or shallow breathing and these interruptions lead to a drop in oxygen levels (hypoxia). The body responds by releasing stress hormones like adrenaline (catecholamines), which increases the heart rate and constricts blood vessels, raising blood pressure. OSA also causes sympathetic nervous system activation which causes increased heart rate, blood vessel constriction, and over time, sustained increases in blood pressure. Further, OSA is associated with systemic inflammation and dysfunction of the endothelium (the lining of blood vessels). Chronic inflammation and endothelial damage can impair the ability of blood vessels to dilate properly, contributing to higher blood pressure. OSA can lead to fluid retention leading to increased blood volume and increased blood pressure.

In May 2025, a VA examiner opined that it was less likely than not that hypertension was proximately due to or the result of a service-connected right ankle disability. The examiner's rationale was that the conditions of hypertension (high blood pressure) and lateral collateral ligament sprain, right ankle are not medically related. The hypertension (high blood pressure) is a separate entity entirely from the lateral collateral ligament sprain, right ankle and unrelated to it. A thorough review of medical literature failed to demonstrate a causal relationship.

The Board finds that entitlement to service connection for hypertension is not warranted.

As an initial matter, there is no evidence that the Veteran's hypertension manifested during service and no evidence that it is otherwise etiologically related to his active service and hypertension did not manifest within one year of his separation from service. As such, service connection for hypertension on a direct basis is not warranted. 

While the March 2025 VA examiner opined that the Veteran's hypertension was at least as likely as not aggravated by OSA, the Board finds that without establishing a baseline severity, the Veteran's hypertension is not aggravated by the Veteran's service-connected OSA. The Veteran has not offered competent and probative medical evidence in support of his service connection claim based on aggravation.  

With regard to whether the Veteran's hypertension was caused by service-connected OSA, while the
 no evidence that the Veteran's hypertension manifested during service and no evidence that it is otherwise etiologically related to his active service and hypertension did not manifest within one year of his separation from service. As such, service connection for hypertension on a direct basis is not warranted. 

While the March 2025 VA examiner opined that the Veteran's hypertension was at least as likely as not aggravated by OSA, the Board finds that without establishing a baseline severity, the Veteran's hypertension is not aggravated by the Veteran's service-connected OSA. The Veteran has not offered competent and probative medical evidence in support of his service connection claim based on aggravation.  

With regard to whether the Veteran's hypertension was caused by service-connected OSA, while the private clinician Dr. Levin provided a detailed rationale for his opinion which found that hypertension was secondary to (caused by) service-connected OSA, Dr. Levin failed to consider that the hypertension diagnosis pre-dated the diagnosis of OSA by many years. Specifically, the Veteran was diagnosed with hypertension in the 1990s and OSA was not diagnosed until 2021. Additionally, while Dr. Levin indicated that hypertension was caused by chronic pain, he did not specify a specific disability which caused pain. Therefore, the private opinion from Dr. Levin is of no probative value. 

The May 2025 VA examiner's opinion weighs against the claim. As noted above, the examiner indicated that it was less likely than not that the hypertension was proximately due to or the result of a service-connected right ankle disability. The examiner considered the relevant evidence of record and the Veteran's contentions and provided a rationale for the opinion. For those reasons, the Board finds the VA examiner's opinion significantly probative. Barr v. Nicholson, 21 Vet. App. 303 (2007); Stefl v. Nicholson, 21 Vet. App. 120 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008).

The Board has also considered the lay evidence of record. The Veteran is competent to describe what he has personally observed or experienced. However, the ultimate questions of diagnosis and etiology in this case extend beyond an immediately observable cause-and-effect relationship and are beyond the competence of lay witnesses. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Therefore, the Veteran is not competent to provide an etiology opinion in this case.

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Accordingly, the Board finds that the benefit-of-the-doubt rule is not applicable as the evidence is not in approximate balance, and entitlement to service connection for hypertension is not warranted. 38 U.S.C. § 5107(b); Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc)

 

 

David H. Robertson

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	A. Cryan, Counsel

The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.